Autologous follicular unit extraction transplant for postburn cicatricial alopecia: A single-center's retrospective case series

BACKGROUND AND RATIONALE

Cicatricial alopecia not only affects patients' appearance but also has negative effects on their physical and mental well-being, as well as their daily lives. Therefore, it is essential to provide proactive treatment to patients.

OBJECTIVE

To explore the clinical effects of autologous follicular unit extraction (FUE) transplantation in the treatment of secondary scarring alopecia caused by burn, and to evaluate its effectiveness.

METHODS

A retrospective observational study has been conducted, which included 41 patients with secondary scarring alopecia caused by burn. All patients underwent initial autologous FUE hair transplantation surgery, and the occurrence of postoperative complications was monitored. Patient satisfaction was evaluated after 12 months post-surgery.

RESULTS

Satisfaction assessments were conducted for all 41 patients. Out of the total, 31 individuals expressed being very satisfied, 7 individuals reported being satisfied, and 3 individuals indicated being not very satisfied. Among the patients, 3 experienced complications, including herpes in the donor area for one patient, temporary hair loss for another patient, and thick scab for the third patient.

CONCLUSION

FUE hair transplantation yields positive results for secondary scarring alopecia caused by burn. It offers natural hair growth patterns, minimal trauma, quick recovery, high patient satisfaction, and few complications.

A new easy technique to identify the correct artificial hair implantation site: A case series and preliminary results

BACKGROUND

The implantation of artificial hair is a successful standardized procedure to restore bald areas or scarred alopecic surfaces of the scalp in both sexes.

MATERIALS AND METHODS

Sebometric measurements were taken, pre, 1, 3, and 6 months postimplant in two symmetric frontotemporal areas of the scalp of seven volunteers to be implanted with 50 units of artificial hair. The artificial hair used in this study are Biofibre 4.0 produced by Medicap srl, Italy.

RESULTS

The dermaroller assisted procedure was performed only on one side, and the plain random implant contralaterally for comparison. A marked downregulation of the sebum concentration was observed in the dermaroller treated area 1, 3, and 6 months later in respect to the control side.

CONCLUSION

The dermaroller assisted procedure is safe and effective in reducing the foreign body reaction by the sebaceous glands and the vascular axis injured by the implanting needle; a longer standing success of the implanted hair can thus be achieved reducing the burden of inflammatory reaction.

Clinical effects of autologous follicular unit extraction transplantation in the treatment of secondary cicatricial alopecia after infections

OBJECTIVE

To explore the clinical effects of autologous follicular unit extraction (FUE) transplantation in the treatment of secondary scarring alopecia caused by infections, and to evaluate its effectiveness.

METHODS

A retrospective observational study has been conducted, which included nine patients with secondary scarring alopecia caused by infections. All patients underwent initial autologous FUE hair transplantation surgery, and the occurrence of postoperative complications was monitored. Patient satisfaction was evaluated after 12 months post-surgery.

RESULTS

At the follow-up, postoperative satisfaction was 88.9% in nine patients, with only one case of postoperative infection and no incidence of skin necrosis, significant bruising and swelling, unnatural appearance or temporary hair loss.

CONCLUSIONS

Autologous FUE hair transplantation is an effective method for treating secondary scarring alopecia caused by infections. This procedure is minimally invasive, resulting in high patient satisfaction and minimal complications postoperatively.

Surgical pearl: Modified hypodermic needle and its cap for guarded prick incision

There are many instruments to prick the comedone before its extraction and scalp during hair transplantation. These instruments are not well guarded, and it can cause deep injury and fear in the patients. Here we described how to guard these needle for safety during procedure.

No-Shave Long Hair Follicular Unit Excision Using an All-Purpose Skin-Responsive Device

Background

Current no-shave long hair-follicular unit excision (LH-FUE) techniques employ recesses (slots, notches, or grooves) in punch tips to reduce the long-hair shaft break rate (SBR) and graft transection rate (GTR). However, these methods demand advanced skills and extended procedure time.

Objective

We aimed to evaluate a skin-responsive FUE technique without the use of recess-tipped punches, accommodating diverse hair and skin types in LH-FUE procedures.

Methods and Materials

We retrospectively analyzed patients who underwent this technique using a UGraft Zeus device at five multinational clinics (Mexico, Colombia, India, United States, and Türkiye) from August 9, 2021, to April 11, 2023. Donor zones were pre-operatively graded for expected difficulty using the Sanusi FUE Scoring (SFS) Scale, ranging from class I (low difficulty) to V (high difficulty).

Results

Among 152 patients (mean age, 46 years; 146 straight-wavy, 6 curly-coiled hair), most (n=107) were class I donors. The GTR ranged 2.2%-4.3%, and was highest in class IV donors and those with thick-firm scalps. The SBR was 12.2%, and the average graft excision rate (GER; speed) was 440 grafts/h. Only 19G and 18G punches were used. All patients were satisfied with the procedure, with 57.4% reporting that they were "very happy". Surgeon willingness to perform no-shave LH-FUE significantly increased from 1.25 to 4.20 (on a scale of 1-5) after adopting this device. SFS class, skin thickness, and firmness, more than hair curliness, influenced the GTR, SBR, torque, and punch movement duration.

Conclusion

Our findings reveal consistent success in conducting no-shave LH-FUE using this skin-responsive device across diverse patients. Notably, success was achieved without recess-tipped punches, resulting in low GTR and SBR, along with a high GER and increased patient satisfaction. These outcomes suggest enhanced procedure speed and ease of use, contributing to a greater willingness among surgeons to adopt this technique.

Application of hair transplantation combined with platelet-rich plasma injection for the treatment of androgenic alopecia

Androgenic alopecia is a type of hair loss condition that is influenced by both genetic and environmental factors. This study aimed to investigate the effectiveness of combining hair transplantation with platelet-rich plasma injection for treating androgenic alopecia. From June 2019 to September 2021, a total of 147 patients with androgenic alopecia were selected and treated by our department. Out of these, 72 patients were assigned to the treatment group and received hair transplantation along with platelet-rich plasma treatment. The remaining 75 cases constituted the control group, receiving only hair transplantation. Clinical data was obtained by reviewing the patients' medical records and case reports. The area of hair loss in the treatment group was significantly smaller than that in the control group. The score of the hair pulling test in the treatment group was significantly lower than that in the control group. The hair regeneration score in the treatment group was significantly higher than that in the control group. After treatment, the total area of skin lesions in the treatment group was significantly reduced compared to the control group. There was a statistically significant difference between the two groups. Our study indicates that combining hair transplantation with platelet-rich plasma is superior to hair transplantation alone for the treatment of androgenic alopecia. This combination therapy shows promising potential for clinical applications.

Medical and procedural treatment of androgenetic alopecia - Where are we?

Novel medical and procedural options for androgenetic alopecia have arrived. Low-dose oral minoxidil has made its clinical debut, while data on spironolactone, finasteride, and nutritional supplements have advanced. Minimally invasive technological advancements include photobiomodulation and platelet-rich plasma. Within hair transplantation, follicular unit extraction and robotics are now at the clinicians' fingertips.

Recurrent facial microcystic adnexal carcinoma and hair transplantation on scar site

Microcystic adnexal carcinoma (MAC) is a rare kind of cutaneous neoplasm with a very aggressive local infiltration that destructs the affected tissues. Its rate of recurrence is high and it mostly involves the face and scalp regions and most of the patients get affected in the fourth or fifth decades of their life. Here in, we report a 61-year-old woman with a right-sided eyebrow MAC lesion with recurrency. Total excisional surgery was performed. A-T Flap surgery was applied on the involved area, and after a 2-year period of follow-up, with no recurrency, hair transplantation with follicular unit transplantation method was successfully performed on the scarred area. Although microcystic adnexal carcinoma is an uncommon neoplasm; dermatologists and ophthalmologists should consider it as a differential diagnosis, due to its aggressive local infiltration. Complete surgical excision and long-term follow-up must be applied to manage the disease. Also, hair transplantation with follicular unit transplantation technique can be considered as a beneficial method for treating scars resulted from MAC excisional surgery.

Assessment of quality of life and self-esteem in male patients with androgenetic alopecia before and after hair transplantation

BACKGROUND

Patients with androgenetic alopecia experience a significant decrease in self-esteem and quality of life. There are several methods by which these factors may be improved.

AIMS

Determining whether patients feel better about themselves with a better quality of life after undergoing hair transplant procedure.

PATIENTS/METHODS

35 people were chosen from Jordan Skin and Hair Clinic in Tehran, Iran. Following hair transplant, follow-up subjects had their quality of life and level of self-esteem assessed using the Rosenberg Self-Esteem Scale (RSES) and Dermatology Life Quality Index (DLQI), respectively. The means of quantitative results were compared using paired T-test. The chi-square test was done to compare preoperative and postoperative characteristics qualitatively. Differences were regarded significant if p < 0.05. Analysis of covariance was applied to evaluate the effect of marital status and educational level on outcome variables (ANCOVA).

RESULTS

Our findings showed a statistically significant difference (p < 0.001) between pre- and post-operative hair transplantation for quality of life, and mean score increased to 2.17. There was a statistically significant difference between the two groups, with an average self-esteem score on RSES rising to 5.35 (p < 0.001). A statistically significant link between educational achievement and quality of life was found (p < 0.001).

CONCLUSION

This study found postoperative psychological aspects of AGA patients significantly improve than preoperative. Our results show that there is a statistically significant difference between the self-esteem and quality of life of AGA patients before and after hair restoration surgery.

An assessment for measuring loneliness, anxiety, and depression in male patients with androgenetic alopecia undergoing hair transplantation surgery: A before-after study

BACKGROUND

Androgenetic alopecia has a significant influence on the patients' loneliness, anxiety, and depression, although there are numerous strategies to improve the patients' loneliness, anxiety, and depression.

AIMS

Determine whether hair transplant operation improves loneliness, anxiety, and depression in patients.

PATIENTS/METHODS

There were 35 patients recruited from the clinic. Using questionnaires (UCLA and HADS), the subjects were evaluated for their levels of loneliness, anxiety, and depression before and after hair transplant. To compare the means of quantitative outcomes, a paired t-test was administered. The Chi-square test was employed to compare qualitatively the preoperative and postoperative measures. An analysis of covariance (ANCOVA) was used to assess the impact of marital status and educational level on outcome variables. If p < 0.05, differences were deemed significant.

RESULTS

Our findings demonstrated a statistically significant difference (p < 0.001) between pre- and post-operative hair transplantation for HADS-anxiety and depression, with the mean anxiety and depression score improving to 3.32. In terms of the UCLA, there was a statistically significant change between the two groups (p < 0.001), and the average loneliness score improved to 4.48. There was also a statistically significant relationship between marital status and loneliness (p < 0.001), educational level and loneliness (p < 0.001), anxiety and depression (p < 0.001).

CONCLUSION

This research found that hair transplantation surgery improves psychosocial outcomes, with affected patients experiencing less loneliness, anxiety, and sadness after surgery than before.

Clinical and dermoscopic evaluation of follicular unit transplantation vs. Mini-Punch grafting in the repigmentation of resistant and stable vitiligo: A comparative study

BACKGROUND

Various surgical modalities and transplantation techniques had been evolved for the treatment of recalcitrant stable vitiligo. Each of these techniques has its own limitations and side effects. There are insufficient studies evaluating the efficacy of transplantation of hair follicle (HF) units as a surgical modality for vitiligo treatment in comparison with the classic mini-punch grafting.

OBJECTIVES

To compare the efficacy and safety of follicular unit transplantation (FUT) with mini-punch grafting (mPG) in cases of resistant and stable vitiligo.

METHODS

Twenty-five patients with stable vitiligo were included. Treated areas were classified into 2 groups: group I: Areas were treated with the FUT technique and group II: Areas were treated with mPG technique. Treated areas were exposed to narrowband ultraviolet B phototherapy for 6 months. After 3 months, follow-up patients' response was evaluated clinically and by dermoscopy.

RESULTS

Both techniques showed efficacy in repigmentation of stable vitiligo. Group II showed a statistically significant higher percentage of repigmentation and significant earlier repigmentation than group I. Cobblestone-like appearance was the major complication in group II, while no serious side effect was reported in group I. Leukotrichia was present in 8 patients, and 6 of them showed hair repigmentation evidently in group I.

CONCLUSION

Both techniques are effective, safe, and inexpensive methods of surgical repigmentation of stable localized/segmental vitiligo. mPG gives earlier and better percent of repigmentation, with higher incidence of cobblestoning. FUT is a good alternative for mPG, especially in hairy areas with better cosmetic outcome and minimal complications.

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.

Evaluation of efficacy of follicular unit extraction versus follicular unit extraction with platelet rich plasma in treatment of cicatricial alopecia

BACKGROUND

Follicular unit extraction (FUE) is a minimally invasive surgery that is becoming popular in hair restoration in cicatricial alopecia (CA).

AIM

Evaluation of FUE with or without platelet rich plasma (PRP) in scarring alopecia.

PATIENTS AND METHODS

Twenty patients with CA were randomized into two groups. Group A (10 patients) underwent FUE, group B (10 patients) underwent FUE + PRP. PRP was injected 1 week before surgery, then monthly after surgery for 3 months. Follow up was done after 3, 6 and 12 months by calculating the density of surviving follicular units and the survival rate.

RESULTS

In group A, there was statistically significant increase in mean survival rate which was 30.30%. At 3 months, 67.26% at 6 months and 78.15% at 12 months. In group B, there was a significant increase in mean survival rate being 30.14% at 3 months, 58.75% at 6 months and 69.74% at 12 months. There was no significant difference between both groups at anytime during follow up period.

CONCLUSION

Follicular unit extraction is a preferred procedure for hair restoration in CA with few side effects. The role of PRP in HT is controversial. In the present study, PRP does not significantly affect the survival rate of hair grafts.

Treatment of scarring alopecia in children using follicular unit hair transplantation

BACKGROUND

Scarring alopecia can significantly affect children emotionally. Follicular unit excision (FUE) and follicular unit transplantation (FUT) have been applied for scar treatment.

OBJECTIVE

This study aimed to evaluate the safety and feasibility of follicular unit hair transplantation in treating scarring alopecia in children.

PATIENTS AND METHODS

A total of nine children (seven males and two females) with cicatricial alopecia, ranging in age from 5 years, 2 months to 12 years, 10 months were included in this study. Scar formation time ranged from 7 months to 5 years. Sites were vertex (2), eyebrow (3), frontal hairline (3), and temporal regions (2).

RESULTS

Nine children in this group were followed up for 6-34 months with the following treatment options: FUE (5 cases), FUT (3 cases), and FUT combined with FUE (1 case). No significant complications were observed during the treatment. The transplanted hair grew well, the direction and shape were satisfactory, and the survival rate was >90%.

CONCLUSION

For children with burn trauma and cicatricial alopecia after surgery, hair transplantation can significantly improve their appearance with low surgical risk and high patient satisfaction rate.

Oral clonidine as a pre-anesthetic medication in hair transplantation surgery-A pilot study

BACKGROUND

Hair transplantation (HT) is a safe and rewarding procedure for a patient as well as the surgeon. Clonidine may be a good adjuvant in HT because of its analgesic, anxiolytic, and sedative effects.

OBJECTIVE

To study efficacy of Clonidine as a preoperative medication in HT.

METHODS & MATERIALS

The study was a prospective trial of 46 consecutive patients who underwent HT between January and May 2017. Patients with normal vital parameters on arrival were given Tab clonidine (0.1 mg) 30 min before starting of the procedure [Clonidine group (n = 30)]; rest were included in the control group (n = 16). Vitals were monitored every 30 min during surgery until the end. Patients were assessed for pain, level of sedation during surgery and for postoperative analgesia.

RESULT

All patients who received clonidine, except one, were comfortable and experienced no pain throughout the duration of surgery; nine went into deep sleep. Of the 16 patients in the control group, no patients reported deep sleep, 3 felt restless, and 4 had mild pain. There were no untoward effects in both groups.

CONCLUSION

Our study suggests that clonidine is useful as a pre-anesthetic medication in HT. However, this is a pilot study and further larger studies are needed.

Patient Counselling and Medicolegal Aspects of Hair Transplant Surgery

Hair transplantation being an elective aesthetic surgery, the importance of informed consent cannot be overstated. Explaining the condition of hair loss, the causes, progress, prognosis, and all available treatment options is a part of this process. Providing conflict-free information, ensuring that the patient comprehends this information, and allowing him/her to make the decision to authorize the surgeon to perform the procedure is the moral obligation of the hair transplant surgeon. The benefits of this approach are noticeable and one of the most effective ways to have a satisfied patient and reduce the possibility of claims.

Histopathological Evidence of Occipital Involvement in Male Androgenetic Alopecia

Background: The occipital region of the scalp is generally accepted as an unaffected area of androgenetic alopecia (AGA) for both genders. However, evidence of AGA involving the occipital scalp has been demonstrated in women; meanwhile, it is unclear whether occipital involvement also occurs in men. Objective: We aimed to determine if there is occipital involvement in men with AGA. Methods: This case-control study compared hair counts of scalp biopsy specimens from the occipital region of 82 men with Hamilton-Norwood III-VII and 82 unaffected men. Results: The mean ages of men with AGA and controls were 40.1 ± 8.9 and 38.6 ± 10.5 years, respectively (P = 0.291). A significant decrease in total hair follicles, terminal hair follicles, follicular units and terminal to vellus (T:V) ratio, along with a significant increase in follicular stelae was indicated in the AGA group compared to controls (all P < 0.05). Subgroup analyses revealed that average counts of total hair follicles, terminal hair follicles and T:V ratios were also significantly lower in males with Hamilton-Norwood VI and VII than in controls (all P < 0.05). There were no correlations between increasing age and hair count parameters, but a significant negative association was found between total follicle numbers and disease duration (r = -0.23, P = 0.02). Conclusions: AGA can involve the occipital area of male patients with advanced disease. Therefore, the occiput of particular cases should not be used to determine reference data for normal scalp hair, and preoperative measurements of miniaturized hairs in the donor site are strongly recommended in all persons undergoing hair transplantation.

Successful follicular unit extraction in a case of inactive, recalcitrant alopecia barbae

Alopecia areata (AA) is a non-scarring autoimmune type of alopecia. Hair transplantation in AA is not practiced as the implanted follicular grafts might be destroyed due to underlying autoimmune pathology. A biopsy proven 28 year old male patient of AA presented to us with an 8-year history of a hairless patch over the beard area. He underwent many treatments by other dermatologist with oral, topical, and intralesional immunosuppressants, which curtailed his disease progression but failed to re-grow hair. Biopsy during his visit revealed absence of inflammatory infiltrates and empty hair tracts replaced by fibrotic tracts. Follicular unit extraction (FUE) was done successfully after counseling the patient about the controversial role of hair transplant surgery in AA. Hair growth was achieved within 6 months with no recurrence during 1-year follow up. FUE can be opted for long-standing and clinically stable cases of AA; histopathology and dermoscopy being the guiding lights in determining the disease inactivity.

Ergonomics in follicular unit excision surgery

BACKGROUND

Concentration and physical strength are essential for the long duration of hair transplant surgery. Because both the patient and the doctor must maintain certain postures for long periods, the importance of ergonomics cannot be understated.

AIMS

To review the devices, instruments, and techniques developed for ergonomic follicular unit excision surgery, to present our experience with various ergonomic modifications, and to evaluate the effectiveness of the related devices, novel concepts, and methods.

METHODS

We evaluated the scientific evidence supporting the ideas, methods, devices, and systems to help create a better ergonomic environment, and we investigated how these elements can be fine-tuned to improve efficiency when performing follicular unit excision graft harvesting.

RESULTS

Through innovative methods, ideas, devices, and instruments, the authors achieved a high-quality ergonomic environment for performing follicular unit excision.

CONCLUSION

Follicular unit excision is a widely used technique in hair restoration surgery. However, follicular unit excision is a very laborious and time-consuming procedure and mandates the best ergonomic conditions for both the surgeon and the patient. Therefore, it is crucial that the physician understands and appropriately adopts the various means and techniques to provide an ergonomic environment.

Hair transplantation Follicular Unit Excision (FUE): Introducing the multipurpose octagonal ring punch

The technique of follicular unit excision for harvesting grafts for hair transplantation procedures has become very popular. This technique relies on the use of small punches to remove viable grafts. Many different punch shapes have been developed to accommodate the varying nature of skin and hair characteristics, resulting in hair transplant surgeons requiring a variety of punches to suit a wide range of patients, which can be overwhelming to the beginner when trying to decide on the optimal choice of a punch to suit a particular skin characteristic. We describe a novel multipurpose ring punch that can be used on patients with a variety of skin and hair characteristics, as well as for shaved and long hair FUE. Features of this punch include an octagonal ring that protrudes from the outer wall of the punch and functions to control the punch's trajectory into the deeper dermis during incision. Additionally, this punch has a dull, notched edge which allows for use in long hair and shaved FUE without sacrificing ease of incision through the epidermis. This punch is the first of its kind to have this breadth of versatility with a one-size-fits-all design.

Modified single-hair follicular unit grafting to esthetically restore eyelashes in Asians

BACKGROUND

Eyelashes play an important role in the perception of beauty and protection of eyeballs. The outcome of eyelash restoration varies and mainly depends on the surgeon's technique and no standard procedure exists.

AIMS

To evaluate the effect of modified single-hair follicular unit grafting to esthetically restore eyelashes and provide a potential alternative of standard procedure.

PATIENTS AND METHODS

A total of 34 patients with sparse or partially absent eyelashes who underwent modified procedure were included. Single-hair grafts were harvested from the donor site (post-auricular, nape, frontal hairline area). Grafts were transplanted with 23 gauge needle and fine forceps in the modified procedure. The patients were followed for a mean of 12 months after surgery.

RESULTS

All patients were satisfied with the result 12 months after the surgery. An average of 46.5 grafts (34-68) were transplanted in each upper eyelid. The mean graft survival rate after 1 year was 87.2% (84%-92%). Of the 34 patients, three patients received a second session to achieve a denser appearance. No significant complication as trichiasis, infection, scarring, or eyeball injury occurred.

CONCLUSION

This modified single-hair follicular unit grafting is a good alternative for esthetic eyelash restoration with good cosmetic results, relative easy maintenance, lack of complications, and long-term patient satisfaction.

Hair diameter measurements for planning follicular unit extraction surgery (FUE): Is there a correlation between the micrometer caliper and scanning electron microscopy (SEM) findings?

BACKGROUND

Hair shaft diameter is one of the most important factors for the outcome of follicular unit extraction (FUE) surgery. In fact, the hair shaft is elliptical. Therefore, it has a long and short axis. Many hair transplantation surgeons use manual micrometer caliper for gauging hair diameter and use the results in the management of recipient and donor area.

AIM

In this study, we aimed to identify the dependability of micrometer caliper and also the hair diameter diversity pattern in the donor area.

PATIENTS/METHODS

Two hundred and seventy hairs were collected from three males with androgenetic alopecia. Hair samples were obtained from the 1 cm² boxes from superior to inferior at the mid-point of temporal, parietal, and occipital donor areas. The diameter of each hair was measured both with a micrometer caliper and scanning electron microscopy (SEM).

RESULTS

Average diameter measured by scanning electron microscopy was 83.01 µm for the long axis and 51.51 µm for the short axis. The average value for the micrometer caliper measurement was 53.32 µm. Comparison of micrometer caliper results with the short-axis measurements of SEM revealed a strong significant correlation. The hair diameters from superior, middle, and inferior boxes revealed a tendency to decrease toward the inferior regions.

CONCLUSIONS

A manual micrometer caliper is a dependable tool for planning FUE surgery, and it measures the short axis of the elliptical hair shaft. Hair diameter tends to decrease toward the inferior regions of the donor area.

Design of In Vitro Hair Follicles for Different Applications in the Treatment of Alopecia-A Review

The hair research field has seen great improvement in recent decades, with in vitro hair follicle (HF) models being extensively developed. However, due to the cellular complexity and number of various molecular interactions that must be coordinated, a fully functional in vitro model of HFs remains elusive. The most common bioengineering approach to grow HFs in vitro is to manipulate their features on cellular and molecular levels, with dermal papilla cells being the main focus. In this study, we focus on providing a better understanding of HFs in general and how they behave in vitro. The first part of the review presents skin morphology with an emphasis on HFs and hair loss. The remainder of the paper evaluates cells, materials, and methods of in vitro growth of HFs. Lastly, in vitro models and assays for evaluating the effects of active compounds on alopecia and hair growth are presented, with the final emphasis on applications of in vitro HFs in hair transplantation. Since the growth of in vitro HFs is a complicated procedure, there is still a great number of unanswered questions aimed at understanding the long-term cycling of HFs without losing inductivity. Incorporating other regions of HFs that lead to the successful formation of different hair classes remains a difficult challenge.

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].

Preview long hair follicular unit excision: An up-and-coming technique

BACKGROUND

Follicular unit excision (FUE) is a popular hair transplant technique, but requires shaving the donor area. This is a deterrent for some patients wishing to keep their hair transplant discreet. The new long hair FUE technique avoids shaving the donor area, which appeals to a wider patient population; however, it has a reputation of being technically challenging and slow.

AIMS

We review the tools and techniques developed for long hair FUE and present our experience using the Trivellini Long Hair System and Long Hair punch.

DISCUSSION

With the new advances in tools and techniques for long hair FUE, this method is gaining momentum and has the potential to be the next trend in the hair transplant industry. There are a few different punch designs marketed specifically for long hair FUE (window/slotted, Trivellini Long Hair, and bi-pronged). Although this technique is slower to perform than shaven FUE, graft survival and final outcome are comparable.

CONCLUSIONS

Innovations in technology have made the long hair FUE technique more accessible to hair transplant surgeons. It is important for hair restoration surgeons to keep knowledgeable about this technique in order to maintain a competitive business.

The assessment of Hair Transplantation Outcomes in Cicatricial Alopecia

Background

Cicatricial alopecia (CA) is scarring alopecia due to a diverse group of disorders which destroy the hair follicle, replace it with scar tissue causing permanent hair loss. Spontaneous regrowth of hair in CA is rarely seen and thus it has a negative impact on the self-esteem of the patient. However, hair transplantation (HT) has emerged as an effective modality of treatment to replace lost hair for cosmetic benefit.

Materials and Methods

This was a prospective analysis of patients affected with CA, who underwent HT from January 2015 to December 2017. Demography of patients along with the duration of disease, stability, biopsy, technique of HT, number of grafts, and other procedures done were noted on a pro forma and analyzed. A test patch of HT was done in all primary CA to assess stability and few secondary CA to look for graft uptake. The patients were followed up for a year and the outcomes were graded by patient and a single observer on a 10 point scale as poor, satisfactory, good, and very good at 3, 6, and 12 months.

Results

A total of 50 patients with CA underwent follicular unit extraction. Majority of them were males(84%) with a male to female ratio of 5.25:1. Secondary CA was seen in majority(90%) of the study group. Moustache (56%) was the most common site affected, followed by scalp (22%), beard(14%) and eyebrow(8%). Around 38%(12 atrophic scars; 7 hypertrophic scars) underwent fractional CO2 laser/Erbium YAG laser with or without intralesional steroid injections in a stepwise manner prior to HT. Excellent-to-very good outcome was seen in 82% while 18% were lost for follow up.

Conclusion

Scarring in CA has a significant effect on quality of life of affected patients. HT when done taking into consideration the stability of disease has good-to-excellent outcomes thus leading to a positive impact on the patient's life.

The effect of hyperbaric oxygen therapy combined with hair transplantation surgery for the treatment of alopecia

BACKGROUND

Transplanted hair follicles suffer from various injuries, which are difficult to prevent. Hyperbaric oxygen therapy (HBOT) was reported to be an excellent procedure to promote capillary regeneration and reduce ischemia-reperfusion injury.

AIM

To evaluate the clinical efficacy of HBOT as an adjuvant therapy for hair transplantation surgery.

METHODS

Thirty-four patients with II-IV alopecia were divided into the control group and HBOT group randomly. The control group was treated with routine FUE procedure, while HBOT group combined with HBOT. Patients were treated with 100% oxygen under 2.0 atmospheres absolute pressure for 60 minutes through a facemask during HBOT and take the therapy daily for 7 days continuously after operation. Satisfaction and clinical improvement were evaluated at the fourth week and the sixth month postoperatively.

RESULTS

Itching and folliculitis were significantly decreased in HBOT group (11.8% vs 35.3%). In addition, HBOT resulted in a lower postoperative shedding rate (27.6 ± 2.6% vs 69.1 ± 2.4%); nevertheless, the survival rate at 9 months showed no significant difference between HBOT (96.9 ± 0.5%) and control (93.8 ± 0.6%). The early postoperative satisfaction in control group was much lower than HBOT group (52.9% vs 88.2%), whereas all patients showed satisfaction with the final result.

CONCLUSION

Hyperbaric oxygen therapy is able to minimize the postsurgical follicle shedding and lead to less folliculitis and itching, which provides evidence for HBOT to act as an adjuvant therapy for hair transplantation surgery.

Comparative study between follicular unit transplantation with intact and non-intact hair bulb in treatment for stable vitiligo

OBJECTIVE

To compare the cosmetic efficacy of the transplantation of follicles with intact and non-intact hair bulbs in the treatment for vitiligo.

METHODS

The single-hair follicle units with intact hair bulbs and un-intact hair bulbs were transplanted into the skin of vitiligo. The diameters of regrowing hair shafts and repigmentation of implanted follicles were detected analyzed by dermatoscopy (Beining BN-PFMF Skin and Hair Visualizer).

RESULTS

The survival rates of follicles with intact and non-intact hair bulbs were 60.00% and 50.62%, respectively. The average diameters of hair shafts and repigmentation of the two groups were 92.83 ± 7.26 µm vs 55.86 ± 2.64 µm (p < .05), 2.62 ± 0.13 mm vs 2.63 ± 0.17 mm (p > .05), respectively.

CONCLUSION

Single follicle transplantation was an alternative effective choice for the treatment of vitiligo. The skin implanted with follicle with non-intact hair bulb was less hairy.

Characterization and classification of different female hairline patterns in the Thai population

BACKGROUND

The hairline is an essential component of the human face. Disfigurement of the hairline may cause physical and psychological problems. Standard guidelines do not exist for female hairline designs, average values of infratemporal portion, hairline classifications, and preferences.

AIMS

We aimed to study hairline characteristics in Thai females and further compare the values with previous studies in different populations. Furthermore, we aimed to introduce a comprehensive hairline classification system that allowed an easy and detailed phenotypic characterization of female hairline.

PATIENTS/METHODS

Healthy Thai females aged over 18 years were included in the study. Collection of demographic data, infratemporal measurements, and standard photography was performed. All collected data were analyzed to determine the standard values of each hairline dimension for comparison to previous studies.

RESULTS

Two hundred and twenty-nine females, with a mean age of 32.4 ± 8.6 years, participated in this study. The mean mid-frontal line was 6.45 ± 0.89 cm, which was not correlated with age. Lateral mounds, widow's peaks, and cowlicks were observed in 42.35%, 24.45%, and 1.74% participants, respectively. Our study revealed five patterns of the frontal hairline and four patterns of the temporal hairline. The mid-frontal line in Asian females trended longer than that in Caucasians, without statistical significance.

CONCLUSIONS

Measurements of the infratemporal portions in Thai females revealed no change with age, and the mid-frontal line showed no statistically significant differences between Korean and Turkish participants. The hairline classification system introduced in our study was comprehensive and would be easily applicable in clinical practice. Female hairline dimensions and patterns reported in our study could provide reference values for hairline design in hairline restoration surgery as well as assist in accurate diagnosis of hair disorders.

Follicular Transplantation, Microneedling, and Adjuvant Narrow-band Ultraviolet-B Irradiation as Cost-Effective Regimens for Palmar-Plantar Vitiligo: A Pilot Study

Treatment of refractory palmar-plantar vitiligo is particularly challenging because the skin in these regions has a limited supply of follicle-derived melanocytic stem cells. Autologous hair transplantation monotherapy is effective in some forms of vitiligo through the provision of melanocytic stem cells. CO₂ laser followed by exposure to light (i.e., sunlight or narrow-band ultraviolet-B [nbUVB]) has independently shown to be an effective treatment strategy. Recently, it was found that the combination of hair transplantation and CO₂ laser followed by nbUVB exposure had superior efficacy to either modality as monotherapy. Similar to CO₂ laser, microneedling produces skin cell proliferation and releases pro-pigmentary cytokines. Given the important role of the cytokines in vitiliginous skin, microneedling may also be an effective therapeutic modality for refractory vitiligo. Herein, we conducted a pilot study to evaluate the efficacy of hair transplantation and CO₂ laser or microneedling followed by nbUVB. Microneedling and fractional CO₂ laser in combination with hair transplantation and nbUVB both demonstrated utility in the induction of repigmentation in refractory palmar-plantar vitiligo; however, a larger trial would be needed to determine a difference in treatment efficacy. Nonetheless, microneedling is cost-effective and requires minimal training; therefore, microneedling can be easily incorporated into standard dermatological practice.

Theoretical basis and clinical practice for FUE megasession hair transplantation in the treatment of large area androgenic alopecia

BACKGROUND

Large area androgenic alopecia patients seeking hair transplantation treatment has become common. FUE Megasession has become a choice for more and more people. Long-term in vitro preservation of hair follicles during FUE Megasession has become a new challenge.

OBJECTIVE

To explore optimal in vitro preservation condition according to FUE Megasession long-period surgery time and to perform clinical practice to confirm the feasibility.

METHODS

Human follicles were obtained from informed patients by FUE Megasession and preserved under different conditions. Live and dead staining with DAPI was used to assess the survival rate of cells. Hair follicles were preserved in vitro for 7 days under different conditions, and the extension of the hair shaft was observed. We also performed some clinical procedures to illustrate the effectiveness of these methods.

RESULTS

Under the condition of 4℃ Ringer's solution, the death rate of hair follicle cells was lower than that of the rest. 4℃ Ringer's solution supported superior growth of the hair follicle unit according to organ culture. 8-h preservation in 4℃ Ringer's solution was kept as high survival rate as the traditional hair transplantation surgery（P > .05）. Clinical procedures confirmed the feasibility of FUE Megasession hair transplantation surgery.

CONCLUSION

4℃ Ringer's solution in vitro preservation is optimal for clinical FUE Megasession surgery which ensures the hair follicle survival rate and postoperative results.

Approach to Hair Transplantation in Advanced Grade Baldness by Follicular Unit Extraction: A Retrospective Analysis of 820 Cases

Background:

In advanced grade baldness (Norwood 5–7), hair restoration has been considered difficult due to the donor recipient area mismatch. In this article, we have given a comprehensive methodical approach to manage these cases.

Objective:

To assess the outcome and challenges faced with follicular unit extraction (FUE) and to plan a successful management in advanced grade baldness in 820 cases of androgenic alopecia.

Materials and Methods:

A retrospective analysis of 820 male patients with advanced grade of baldness (grade 5–7) treated by FUE. The patients were divided into five groups based on the extent of scalp coverage, for example, frontal coverage, frontal + mid-front coverage, vertex, full coverage, and frontal forelock only. The results were analyzed at 6, 9, 12, and 24 months.

Results:

At 12 months, 94% patients were satisfied with the results, whereas 62% wanted another sitting for increasing the coverage area/density.

Conclusion:

Hair transplantation can give natural and aesthetic results even in advanced baldness. Beard and body hairs can be used to augment results in cases with limited donor supply. A mature hairline with an adequate density in a gradient, from front to back helps in achieving a satisfactory response even in extensive cases of advanced baldness.

Keloid Scars Arising after Follicular Unit Extraction Hair Transplantation

Hair transplantation is considered safe compared to other cosmetic procedures. However, scarring is still an inevitable potential complication. Keloid scarring is a rare complication of hair transplantation and usually associated with strip harvesting rather than follicular unit extraction (FUE). A case of keloids at the donor site following FUE hair transplantation is presented. Hair transplant practitioners should be aware of the risks of the procedure when considering hair restoration to ensure safer outcomes.

A novel model for designing and performing parietal whorl hair transplantation

BACKGROUND

Hair transplantation is the gold standard method for the treatment of alopecia. Recently, demand for the surgery has increased rapidly. However, high demands also require more professional training for the surgeons. With the maturing of hairline design skills, parietal whorl design has become the next challenge and no appropriate training models have yet been reported.

AIMS

To present an innovative, simple, and appropriate training model for designing the scalp parietal whorl.

METHODS

Outward divergent arc curves were drawn from the navel of an orange. Recipient sites were created with 23G needles or 1.0-mm knives or 1.0-mm blades according to the outward divergent arc curves, then hair shafts were transplanted using forceps.

RESULTS

Different densities of hair shafts were transplanted. Transplantation of 10-20 follicular units (FU)/cm² was too sparse, 30 FU/cm² achieved a good appearance, but 40-50 FU/cm² was better. Through practicing on the model, excellent results of parietal whorl transplantation on patients can be achieved.

CONCLUSIONS

This new model can perfectly suit the lines and direction of the parietal whorl and also present different density transplantation practicing. We provide a training method for new surgeons as well as a rehearsal opportunity for previously trained doctors.

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.

Marking of temporal point and lower border of temporal triangle in planning hair transplantation for male-pattern baldness

Introduction:

Temporal recession in male-pattern baldness is common. The method of marking of temporal point practiced worldwide, described by Walter P. Unger, does not help in marking temporal triangle border in Indian population. We have found aesthetically superior way of marking temporal point and easy method of construction of lower border of temporal triangle.

Case Series:

The new marking was applied over 126 young male patients from March 2014 to December 2017; they were regularly followed up and results were observed.

Conclusion:

With the new method of marking, we found that the lower border of temporal triangle can be easily constructed and temporal point can be more aesthetically placed in Indian population.

Controversies in Hair Transplantation

Hair transplantation being a relatively new field, several aspects raise issues and controversies. The issues refer to both ethics and evidence and how practitioners and the community need to deal with them. This article deals with few of such diverse issues as follicular unit transplantation versus follicular unit excision, safe donor area, platelet-rich plasma, and minimum qualification for performing hair transplantation.

Logic of Hair Transplantation

Hair transplant is a seemingly illogical process wherein we are using a small number of hairs to cover a large area of baldness. This is possible if one understands the logic of this equation. Understanding the pattern of hair distribution, and the sequence of balding, helps us learn the limitations of this technique and give the best possible results to the patient. In this article, we aim to give an understanding of all the processes associated with hair transplantation and the logic behind the same.

Current and emerging treatment strategies for hair loss in women of color

Hair loss is common in women of color, and is associated with significant psychosocial complaints. Early clinical recognition and prompt initiation of intervention with medical treatment is critical to halt the disease process. In this article, we review the clinical presentations of nonscarring and scarring alopecias in women of color, use of dermoscopy for early recognition of the disease process, and medical, procedural, and surgical interventions. In conditions that result in scarring alopecia, such as late-stage traction, frontal fibrosing, or central centrifugal cicatricial alopecia, patients may benefit from procedural interventions, such as hair transplantation, platelet rich plasma injections, low-level laser therapy, or scalp therapy.

Use of Implanters in Premade Recipient Sites for Hair Transplantation

Background

Techniques of hair transplantation are evolving with time both in terms of use of better methods of graft harvestment and implantation. The result of the procedure ultimately depends on the tenderness with which grafts are handled.

Aims

The aim of this study was to evaluate efficacy and feasibility of using implanter in premade slits for implantation of the graft.

Materials and Methods

This technique was used in 104 patients who were willing to undergo hair transplantation by follicular unit extraction. After administration of local anesthesia, the recipient sites were created. Thereafter, the processes of scoring the skin with a motorized punch, graft extraction, and implantation using implanter into the premade slits were performed simultaneously. These patients were followed up to look for the time period of initiation of hair growth. Improvement was assessed by comparing basic and specific classification (BASP) at the baseline and during subsequent follow-up.

Results

Of 104 patients, 103 (99%) were men and one (1%) was woman. According to pretransplant BASP score, 98 (94.2%) patients were having severe type and 6 (5.8%) were having mild type. As per the posttransplant BASP score, patients having severe and mild type were 24 and 80, respectively. Improvement in the BASP score (from severe to mild type) was seen in 74 (71%) patients and no change was seen in 30 (29%) patients. Hair growth started becoming visible after two to five months and "good" results were obtained in all except two patients after a follow-up period varying from 8 to 18 months.

Conclusion

Placement of the grafts into premade slits using implanter will help in improved results because of minimal graft handling, more graft placement in less time, and thereby reducing body out of time.

Limitation

No objective assessment was carried out to document regrowth of hair in our study.

Staged reconstructive treatment for extensive irregular cicatricial alopecia after burn

For extensive irregular cicatricial alopecia after burn, effective and pleasing restoration of hair-bearing scalp remains challenging. In this article, the authors presented staged reconstructive treatment for extensive irregular cicatricial alopecia with the goal to achieve better and reliable results. A retrospective review of staged reconstructive treatment performed in 16 patients with extensive irregular cicatricial alopecia after burn was conducted. In stage 1, final flaps were designed at 1st. Tissue expanders were placed into the subgaleal plane and serially inflated with normal saline. In stage 2, scarring tissues were excised and the expanded hair-bearing flaps were advanced to the defect. Hair grafts were harvested from excessive hair-bearing scalps excised from the flaps and replanted. For patients with less satisfactory results, stage 3 was performed by hair transplantation. Cicatricial area, follicular unit density, survival rate of hair grafts, and patients' satisfaction were measured before and after each stage. Thirteen patients received 3-stage treatment, and 3 received 2-stage treatment. Significant improvements in aesthetics and patient satisfaction were achieved in all the patients. No flap necrosis, implant exposure or hematoma was observed. Ideal, aesthetic, and reliable results could be obtained using staged reconstructive treatment for patients with extensive irregular cicatricial alopecia after burn.

Safety concerns when using novel medications to treat alopecia

INTRODUCTION

Alopecia is often a cause of great concern to patients for cosmetic and psychologic reasons. The aim of treating non-scarring alopecias is to reduce hair loss and, to some extent, enhance hair regrowth. However, therapies for scarring alopecias are limited and aiming to halt disease progression. Nonetheless, available modalities of treatment come with numerous side effects. Areas covered: Many new treatments for non-scarring alopecias have been introduced in recent years. This review summarizes the safety concerns when using novel therapeutic modalities such as JAK inhibitors, hair transplantation, mesotherapy, oral minoxidil, platelet-rich plasma, microneedling, and 5α-reductase inhibitors for treating hair loss. A broad literature search was performed using PubMed and Google Scholar in April 2018 to compile published articles that reported the adverse effects of new therapeutic modalities for alopecia. Expert opinion: Although emerging therapeutic modalities for alopecia have demonstrated efficacy in hair regrowth and treating established disease, their safety profiles vary widely. When considering the new treatments for alopecia, physicians should weigh the potential benefits and risks of each treatment or combination treatment to ensure safe and successful outcomes.

Complications in Hair Transplantation

Hair transplantation is a relatively safe surgery and is associated with very few complications. It is a cosmetic surgery so the complications may impact social and psychological aspect of the patient. Every hair transplantation surgeon should be aware of possible complications and techniques for the prevention and techniques of their management. Most of the complications are avoidable and can be minimized by proper surgical technique and wound care. Counseling and discussion with the patient before surgery help in proper planning and avoid patient dissatisfaction. Every patient should be individualized, planned, and operated with an aim to zero-down the complications and complaints.

Autologous Hair Transplantation in Frontal Fibrosing Alopecia

We report a patient with frontal fibrosing alopecia (FFA), in whom autologous hair transplantation was successfully performed despite evidence of active disease. Since the underlying pathology of FFA is usually lichen planopilaris, reservations, and caveats have been expressed with respect to the risk of köbnerization phenomena following hair transplantation surgery. An important question that arises is how the lichenoid tissue reaction pattern is generated around the hair follicles in FFA. Follicles with some form of damage or malfunction might express cytokine profiles that attract inflammatory cells to assist in damage repair or in the initiation of apoptosis-mediated organ deletion. Alternatively, an as yet unknown antigenic stimulus from the damaged or malfunctioning hair follicle might initiate a lichenoid tissue reaction in the immunogenetically susceptible individual. Therefore, it might be expected that the transplantation of whole healthy hair follicles might less give rise to an inflammatory reaction than the disease itself, as revealed in our case report of successful hair transplantation in FFA.

Eyebrow reconstruction

This is a systematic review of eyebrow reconstruction options, using the PubMed database, as well as dermatology and plastic surgery texts. Eyebrow reconstruction options in various clinical scenarios (small, large, medial, lateral, and total defects) are presented. The goals of eyebrow reconstruction are to provide structural, functional, and aesthetic restoration. A good understanding of various eyebrow reconstruction techniques is essential for plastic, dermatologic, and oculoplastic surgeons.