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Clinical experience on follicular unit extraction megasession for severe androgenetic alopecia
Journal of Cosmetic Dermatology
Abstract
Background:
Severe androgenetic alopecia has significant impact on patients' self-image and emotional health. As the most advanced way to achieve the growth of a full head of hair in shortest period of time, the megasession hair transplant procedure is a promising treatment for severe androgenetic alopecia.
Aims:
To introduce the procedure and technical details of follicular unit extraction megasession and to evaluate the surgery outcome.
Method:
A total of 273 male patients undergoing follicular unit extraction (FUE) megasession between 2016 and 2018 were included in our study. The extraction was performed using 1.0 mm punch. The BASP classification degree of patient hair loss, the number of extracted hair, surgery consuming time, and graft survival rate were recorded. We finally evaluated patients' satisfaction with surgery outcomes.
Results:
Ages of patients ranged from 28 to 53 years, with a mean of 42 years (SD, 8.42). All of them were at C3 and U1 degree of BA type hair loss according to the BASP classification. The number of follicular units transplanted was between 3000 and 6000, with surgery duration range from 6 hours to 12 hours and graft survival rate varies from 93.5% to 96.6%. A total of 81% of them were satisfied with the outcomes, 19% of them had a second procedure performed to provide further hair density. None of them had infection after the surgery.
Conclusion:
Compared with multi-stage hair transplantation, FUE megasession has the advantages of reducing operation frequency and overall surgery duration. Thus, FUE megasession is an appealing treatment option for severe AGA patients, who expect to a more desirable natural and esthetically pleasing result in a one-stage operation.
Hair restoration surgery (HRS) is a commonly performed elective procedure but to date lacks a review of the full scope of complications.
To provide a comprehensive overview of observed complications associated with follicular unit extraction (FUE) and follicular unit transplantation (FUT).
Randomized control trials, cohort studies, case series, and case reports published in 1985 or later on adults (age>18). Nontraumatic or autoimmune etiologies of alopecia were excluded as procedure indications.
PubMed, EMBASE, Cochrane databases (last search December 31, 2022).
Data-charting and extraction were independently performed with two reviewers using Covidence.
Forty-three publications were included. Two large series reported the overall complication rate to be 1.2 and 4.7%. Common complications included bleeding requiring intervention (up to 8%), persistent numbness (up to 11%), infection (up to 11% with two reports of Kaposi varicelliform eruptions and one of mucormycosis), effluvium at donor and recipient sites (up to 4.1% and 6.5%, respectively). The most common donor-site complication was hypertrophic scarring/keloid formation after FUT (up to 15.1%). Complications at the recipient site, including crusting (up to 54.8%), frontal edema (up to 50%), and sterile folliculitis (up to 53.3%), tended to be poorly defined with a broad range of incidences.
Serious complications associated with HRS are rare in the hands of experienced providers. However, comprehensive discussions of risk must be had with prospective patients as any complication in the context of an elective procedure may be significant and psychologically devastating for the individual patient.
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.
Hair restoration is considered one of the most exciting and innovative surgical fields in cosmetic surgery today and with modern methods of graft harvesting and implantation, hair transplantation results represent a harmonious blend of art and science.
Background:
Postoperative folliculitis is a common complication of hair transplantation (HT) requiring effective preventive interventions. This study characterized postoperative folliculitis and determined risk factors in patients underwent HT.
Methods:
We retrospectively reviewed 1317 patients who underwent HT and completed 9-month follow-up between January 2018 and June 2021 at four medical centers. The incidence of postoperative folliculitis and patient demographics were assessed. Logistic regression analysis was used to identify risk factors, and the characteristics of different types of folliculitis were compared.
Results:
The overall incidence of postoperative folliculitis was 12.11%, and clinical characteristics varied among the different types of folliculitis. Surgery in summer (odds ratio [OR], 1.772, 95% confidence interval [CI]: 1.05-2.992), number of transplant grafts ≥4000 (OR: 4.818, 95% CI: 1.45-16.014), transplant density >45 grafts per/cm 2 (OR: 2.152, 95% CI: 1.376-3.367), and first nursing time >3 days (OR: 1.555, 95% CI: 1.088-2.223) were the main risk factors for postoperative folliculitis.
Conclusions:
Postoperative folliculitis after HT presents different characteristics. Surgical factors and postoperative nursing were demonstrated to be related to folliculitis. Therefore, we propose a preventive folliculitis model based on preoperative, intraoperative, and postoperative factors.
Background:
Male androgenetic alopecia (MAGA) has been one of the most common reasons for hair consultation, which affects more than half of men under the age of 50. Recently, follicular unit extraction (FUE) megasession has been an attractive treatment option for patients with severe AGA. However, compared with hair transplant surgery by traditional FUE or follicular unit transplantation (FUT), a megasession lacks a suitable surgical design solution for Asian high-grade AGA patients. Therefore, we introduced novel principles for surgical design into FUE megasession for Asians.
Objective:
The goal was to investigate the naturalness of hair, patient and doctor satisfaction level, and safety assessment of FUE megasession with the specific surgical design, to explore a novel technique for an efficient, satisfactory, and safe FUE megasession procedure.
Methods:
Thirty-six Asian male patients with AGA in Hamilton Grade V-VI were enrolled in the research. All participants underwent FUE megasession treatment with the specific surgical design. The investigators observed the patients' general conditions, surgical information, naturalness of hair, and patient and doctor satisfaction level and adverse reactions.
Results:
Before surgery, the average age of patients was 36.8 ± 9.6 years, and average duration of disease was 8.3 ± 3.8 years. During surgery, we harvested an average of 3705 ± 383 grafts. Recipient density ranged from 30 FUs/cm2 to 50 FUs/cm2 , and the total operation time was 10.6 ± 0.9 h. After surgery, patient-rated Likert score for naturalness of hair was as high as 4.72, and the doctor rated 4.61. Patient satisfaction score was up to 4.64, and the doctor scored 4.75. No serious side effects occurred in the study.
Conclusion:
FUE megasession with the introduced surgical design is a satisfactory treatment option for patients with high-grade AGA in Asians, with few side effects. The application of the novel design method can effectively lead to relatively natural density and appearance in one operation. Due to its remarkable effect, high satisfaction level, and few postoperative complications, FUE megasession with the introduced surgical design has great potential for Asian high-grade AGA patients.
Background:
Hair transplantation has become a popular choice for alopecia treatment; however, postsurgical hair shedding still annoys both patients and surgeons.
Objective:
To explore the impact of graft-holding solution on postsurgical hair shedding and testify the protective efficacy of histidine-tryptophan-ketoglutarate solution with adenosine triphosphate and deferoxamine (HTK-AD).
Methods:
There were 240 patients enrolled in the study, and the follicles were placed into either HTK-AD or Ringer solution (RS). Masson staining and live/dead staining were performed to evaluate graft morphology and apoptosis levels, respectively. The between-group comparison of postsurgical graft shedding, survival rate, complications, and patient satisfaction was performed.
Results:
Grafts in HTK-AD maintained organized dense collagen construction and higher cell viability, but those preserved in RS became soft, which hindered implantation. Histidine-tryptophan-ketoglutarate solution with adenosine triphosphate and deferoxamine significantly reduced the incidence of postsurgical hair shedding (73.81% vs 95%), delayed shedding onset, and diminished shedding amount versus RS (p < .05) when ≥3,000 grafts were transplanted. The shedding duration was shortened, and hair regrowth started earlier in HTK-AD versus RS (p < .05); thus, satisfaction was increased. The final survival rate showed no difference between 2 groups.
Conclusion:
Histidine-tryptophan-ketoglutarate solution with adenosine triphosphate and deferoxamine is superior to RS for hair graft preservation because it improves graft viability and alleviates postsurgical shedding.
Hair transplantation is a safe and effective treatment option in patients with male and female pattern
hair loss. Alopecia leads to a lack of self‑confidence and social withdrawal in young patients when
compared to their peers with good hair density. Patient selection, counseling, and planning the
procedure have equal importance as that of the hair transplantation surgery itself. Follicular unit
transplantation (FUT) and follicular unit extraction (FUE) are the two commonly used techniques of
hair restoration. In FUT, a strip of tissue is excised from the occipital donor area resulting in a linear
scar. Whereas in FUE, the scarring can be avoided as small individual follicular units are harvested
and transplanted in the recipient area. FUE is emerging as a most opted hair restoration procedure in
patients with patterned hair loss. This review elaborates on the procedure of FUE in brief and gives
a detailed step-by-step guide for performing the procedure.
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.
Objective
This retrospective study compared the effectiveness of dispersed implantation of very small autologous columnar skin (SCS) grafts and full-thickness skin grafts (FTSGs) for treating upper eyelid third-degree burns.
Methods
Fourteen patients and 26 eyes with granulation tissue formed by third-degree upper eyelid burns were enrolled in the study from August 2017 to June 2020. The experimental group of 6 patients with 11 eyes was treated with SCS grafts. The control group of 8 patients with 15 eyes was treated with FTSGs. The survival rate of the grafts, healing time, SCS diameter, upper eyelid movement distance (ULMD), visual analogue scale (VAS) score for patient satisfaction, and Vancouver Scar Scale (VSS) score were evaluated.
Results
The difference in the survival rate between the two groups was not statistically significant (P=0.06). The ULMD and VAS scores in the experimental group were higher than those in the control group (P<0.05). The healing time was longer in the experimental group than in the control group (P<0.05). The VSS scores of the donor site and the skin grafting site in the experimental group were lower than those in the control group (P<0.05).
Conclusion
Unlike classical skin grafts, SCS implantation surgery can restore the appearance of the upper eyelid, and there is no obvious scar at the donor site. This can be a viable alternative to traditional FTSGs with potential benefits
Background
Surgery is the most effective way to treat bromhidrosis, but postoperative complications are still the biggest obstacles for patients to choose surgical treatment.
Objectives
To introduce an innovative application of follicular unit extraction (FUE) in the treatment of bromhidrosis.
Methods
We conducted a case series study on 20 patients who received FUE technique for the treatment of bromhidrosis. The axillary hair follicles were extracted with a one-millimeter punch. The released hair follicles were collected for histological examination. After the operation, the wounds were wrapped with moderate pressure. The dressing was removed 24 hours after the FUE operation. The postoperative complications were collected, and the improvement of malodor was evaluated by the 10-point visual analog scale (VAS).
Results
Immediately post-operation, many needle-shaped holes appeared in the armpits. The holes healed 7 days after the operation, with no scar or pinpoint-like scars. Except for a female who complained of mild pain in the left armpit, no other patients had any discomfort. The malodor level varied between 0 and 4 during the follow-up period. The tissue examination showed that more than 90% of the completely plucked hair follicles were accompanied by apocrine glands, and many blocked and dilated apocrine glands were observed. The lumens of the blocked glands were filled with decapitation products, which were positive for K5, Brst-2 and CEA.
Conclusions
Patients with bromhidrosis have a positive response to FUE technique. The FUE technique is well tolerated, with only a few postoperative complications, which deserves to be widely promoted.
FUE or follicular unit excision is one of the methods for hair follicle harvesting in hair transplantation. FUE involves harvesting hairs from the donor area, under local anesthesia which is most commonly the scalp but occasionally beard, chest and other parts of the body, using a circular punch less than a mm, mounted on a manual handle or a motorized hand device or more recently a robotic device. First hair transplant was done by Dr Shoji Okuda in 1937. The term “follicular unit extraction” was coined by William Rassman in 2002. The modern era of FUE begins with the work of several surgeons Woods, Rassman, Cole, Harris and Rose. FUE has gone through various stages of development from manual to motorized and blunt to sharp, serrated trumpet and flared punches. Now the use of the robot in FUE with extraction and incision making is also in use. In 2017 nomenclature committee headed by Parsa Mohebi of ISHRS, recommended the term “FOLLICULAR UNIT EXCISION” is most appropriate as it explains the two steps of the process: incision and extraction and incision is done by a physician. FUE is a surgeon based time-consuming procedure with the long learning curve. Use of motorized device and sharp punches has certainly helped to increase speed in an experienced hand. FUE method of hair transplant is the most demanding procedure. If done properly it is a safe procedure. with the experience, use of better quality of instrument the disadvantages of FUE like transection can be reduced. The above informations were collected from various papers published in authentic journals and textbooks.
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.
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.
HER2‐targeted therapies effectively control systemic disease, but their efficacy against brain metastases is hindered by their low penetration of the blood‐brain and blood‐tumor barriers (BBB and BTB). We investigate brain uptake and antitumor efficacy of transferrin receptor (TfR)‐targeted, therapeutic nanoparticles designed to transcytose the BBB/BTB in three murine models. Two known models involving intracranial (IC) or intracardiac (ICD) injection of human breast cancer cells were employed, as was a third model developed here involving intravenous (IV) injection of the cells to form whole‐body tumors that eventually metastasize to the brain. We show the method of establishing brain metastases significantly affects therapeutic BBB/BTB penetration. Free drug accumulates and delays growth in IC‐ and ICD‐formed brain tumors, while non‐targeted nanoparticles show uptake and inhibition only in IC‐established metastases. TfR‐targeted nanoparticles accumulate and significantly delay growth in all three models, suggesting the IV model maintains a more intact BBB/BTB than the other models.
BACKGROUND
Hair restoration surgery is one of the most commonly performed cosmetic surgery procedure in men. The main aim of the study was to know the effect of follicular unit extraction (FUE) follicular unit extraction (FUE) on donor area in terms of hair mass/density.
METHODS
Ten male patients undergoing hair restoration by FUE were included. In each patient, ten boxes of 1 cm² each were marked. The first box was marked in the midline and the 2nd and 3rd boxes were marked about 3 cm from the midline. Another two boxes, each of 1 cm² were also marked at the distance of 3 cm. Two boxes of 1 cm² were marked on either side. The extraction was performed using 0.9 mm punch. The number of extracted hair were counted.
RESULTS
The mean age of the patients was 31.7 years. The average hair count in the donor area was 154.76 hair per cm². The extracted hair count was 54.85 hair per cm² which was about 35.44% of the total donor density (range: 28.9-42.8%). The graft to hair ratio in the extracted follicular units was 1:2.3 (range: 1:1.65-1:2.75).
CONCLUSION
As the donor density varies, the FUE should be performed with caution.
The clinical application of platelet-rich plasma (PRP) is based on the increase in the concentration of growth factors that are released from alpha-granule of the concentrated platelets and in the secretion of proteins which are able to capitalize on the healing process at the cellular level. It has been invented to restore the natural beauty by starting the natural rejuvenation process of the skin and aiming to make it function as a younger one and to keep the skin youthful and maintain it. Besides that, it is also emerged to include hairs as a new injectable procedure to enable stimulating hair growth locally and topically; preventing its fall; improving hair shaft, hair stem, and its caliber; increasing its shine, vitality, and pliability; and declining hair splitting and breakage. Thus, youth is in your blood as it has a magical power imposed in the platelet factors. There is, however, no standardization of the techniques besides insufficient description of the adopted procedures. Not long, autologous platelet-rich plasma (PRP) has surfaced strongly in diverse medical specialties including plastic, wound healing and diabetic ulcers, orthopedic, trauma, ocular surgery, dry eye for eyelid injection, urology for urinary incontinence, sexual wellness, cutaneous surgery, sport medicine, dentistry and dermatology, and aesthetic applications. PRP proved to promote wound healing and aid in facelift, volumetric skin, skin rejuvenation, regeneration, and reconstruction; improve wrinkling; stimulate hair growth; increase hair follicle viability and its survival rate; prevent apoptosis; increase and prolong the anagen hair growth stage; and delay the progression to catagen hair cycle stage with increased density in hair loss and hair transplantation. The aims of this extensive review were to cover all PRP application aspects that are carried out in aesthetic dermatology and to assess the literature on platelet-rich plasma outcomes on main aesthetic practices of general dermatology. A literature review was conducted by searching through PubMed, Biomedical Library database, Google Scholar, and Research Gate for the terms PRP, platelet-rich plasma, platelet-rich fibrin matrix, platelet preparations, platelet application therapy, platelet growth factors, platelet facial, platelet facial rejuvenation, platelet hairs, and platelet wound healing, from inception till 2017, and they were combined using Boolean operators. All those retrieved articles in English language were looked at and explored thoroughly.
Follicular unit extraction (FUE) is a hair transplantation technique that uses small punches (0.8-1 mm in diameter) to extract the follicular units (FUs). Though initially the technique was not widely accepted because of the difficulty of extracting intact follicular units with such small punches, it has since gained in popularity due mainly to rising patient demand, the availability of better instrumentation and greater surgical skill acquired from experience. It is now a recognised alternative to follicular unit transplantation (FUT), a technique based on harvesting the FUs from a strip of tissue. Among the advantages of FUE are less post-procedural discomfort in the donor zone and the barely visible scarring from the punches. However, FUE is a more laborious, time-consuming procedure that involves a long learning curve for the surgeon.
Various classifications for male pattern baldness are mentioned in the literature. The 'Norwood's classification is the most commonly used but it has certain limitations. The new system has included 'three' extra features which were not mentioned in any other classification. It provides an opportunity to document the full and correct picture while documenting male pattern baldness. It also aids in assessing the treatment for various degrees of baldness. © 2016 Journal of Cutaneous and Aesthetic Surgery Published by Wolters Kluwer - Medknow.
Follicular units are commonly used in baldness surgery, and they have become a global procedure for both male and female patients. The yield from micrografts varies between 70 and 85 percent. Yield is determined by factors such as quality of the harvested donor area, preparation of the units, care taken during the implantation procedure, and follicular apoptosis. To improve hair density and stimulate follicular unit growth, an experimental study was designed using platelet plasma growth factors obtained from the patient's autologous plasma.
The author established a protocol within a group of 20 patients with male pattern baldness. The data showed a gaussian distribution; to compare the two procedures involved in this clinical trial, the paired t test was used.
The author observed a significant difference in the yield of follicular units when comparing the experimental with the control areas of the scalp (p < 0.001). The areas treated with platelet plasma growth factors demonstrated a yield of 18.7 follicular units per cm2, whereas the control areas yielded 16.4 follicular units per cm2, an increase in follicular density of 15.1 percent. Among patients who used the experimental protocol, some experienced only 3 percent and others experienced a 52 percent increase in density.
This study provides a new perspective and contribution to baldness surgery with follicular unit megasessions, and demonstrates an improvement that can be introduced into baldness surgery clinics with less morbidity and a low cost-to-benefit ratio. Further studies may improve the efficiency of the technique and allow digital programs to better evaluate the increase in hair density.
Naturalness of the results and reliability of modern grafting technology causes no doubts, but the density of the grown hair as a result of one surgery concerns many surgeons. Everything is perfect in cases when the patient has low class of androgenic alopecia. Problems appear in patients with high classes of male pattern hair loss (V–VII classes by Norwood) with poor donor supply. For obtaining good results, they need huge number of FUs, 6000–12,000 FU transplantation. It’s quite difficult to maximize the donor harvesting. A poor surgical result literally tarnishes hair transplantation—an entire field of medicine. This is the reason why maximizing donor harvesting in hair transplantation (4000 and more grafts) became frequent during the last years. Transplantation of 4000–8000 follicular units (FUs) is intended for the patients with high levels of baldness (Norwood IV–VII classes). Various modifications of the basic technique of follicular unit transplantation (FUT) procedure were proposed recently for the further improvement of the results in patients who need big hair transplant surgery. We have elaborated our own technique of combination of FUT with the follicular unit extraction (FUE) on the both sides of the FUT wound in order to decrease the tension of the scalp when closing the big wound after strip excision. This technique significantly expands the number of grafts that might be transplanted in patients with average and low scalp laxity.
Background:
Androgenic treatment of female-to-male transgender patients may result in androgenetic alopecia (AGA). Use of 5-alpha-reductase inhibitors are useful as oral treatment of AA in men. There are no previous studies of the use of finasteride in transgender men as treatment of AGA.
Aim:
To evaluate the effectiveness and safety of an oral 5α-reductase inhibitor (finasteride) for AA developed in transgender men.
Methods:
This single-centre retrospective study enrolled female-to-male transgender patients with a clinical diagnosis of AGA to receive 1 mg of an oral type II 5α-reductase inhibitor for at least 12 months.
Results:
In all, 10 patients were included in the study. All the patients received a clinical diagnosis of male-pattern AGA, with 90% classified as stage IV on the Norwood-Hamilton scale. Mean onset of AGA was 3.25 years after the introduction of androgenic treatment, and 70% of the patients had a family history of AGA. All the patients improved one grade on the Norwood-Hamilton scale after a mean of 5.5 months (range 4-6 months) since the start of finasteride treatment. Two patients stopped treatment for economic reasons and one stopped due to dyspepsia. No sexual or other adverse effects were observed. Patients were given periodic physical and analytical examinations by endocrinologists without any significant finding. Mean follow-up of patients was 16.2 months.
Conclusion:
AA in transgender men has a delayed onset, and is clinically and therapeutically similar to the common male-pattern-AGA in cis-gender men.
Background:
Androgenetic alopecia, or male pattern hair loss, is a hair loss disorder mediated by dihydrotestosterone, the potent form of testosterone. Currently, minoxidil and finasteride are Food and Drug Administration (FDA)-approved, and HairMax LaserComb, which is FDA-cleared, are the only treatments recognized by the FDA as treatments of androgenetic alopecia.
Objective:
This systematic review and meta-analysis assesses the efficacy of nonsurgical treatments of androgenetic alopecia in comparison to placebo for improving hair density, thickness, growth (defined by an increased anagen:telogen ratio), or subjective global assessments done by patients and investigators.
Methods:
A systematic review of randomized controlled trials was conducted. PubMed, Embase, and Cochrane were searched up to December 2016, with no lower limit on the year. We included only randomized controlled trials of good or fair quality based on the US Preventive Services Task Force quality assessment process.
Results:
A meta-analysis was conducted separately for 5 groups of studies that tested the following hair loss treatments: low-level laser light therapy in men, 5% minoxidil in men, 2% minoxidil in men, 1 mg finasteride in men, and 2% minoxidil in women. All treatments were superior to placebo (P < .00001) in the 5 meta-analyses. Other treatments were not included because the appropriate data were lacking.
Limitations:
High heterogeneity in most studies.
Conclusions:
This meta-analysis strongly suggests that minoxidil, finasteride, and low-level laser light therapy are effective for promoting hair growth in men with androgenetic alopecia and that minoxidil is effective in women with androgenetic alopecia.
Background:
Hair density, together with hair diameter has a tremendous impact on the cosmetic outcome of hair transplantation surgery.
Objective:
This retrospective study aims to assess the average number of follicular unit (FU) grafts in the donor area of Asian men with androgenetic alopecia.
Methods:
Seventy patients (ages 24-65 years old) with virgin scalp who had their first hair transplantation were included. During the harvesting procedure, a 2- to 3-cm-wide area of the donor site was shaved from ear to ear with 5 specific areas assigned as reference points for the study namely the central occipital area, left and right parietal and temporal areas. A video microscope was used to capture the field of each reference point. Follicular units in each area were counted and the number of 1-hair, 2-hair, and 3-hair follicular groupings was recorded.
Results:
East and Southeast Asians had an average of 61.1 FU/cm (111.2 hairs/cm); West Asians had an average density of 63.6 FU/cm (126.8 hairs/cm); South Asians were noted to have an average density of 63.5 FU/cm (126.8 hairs/cm).
Conclusion:
Asian hair density has slight variations in the number of FU grafts in each donor area.
Importance
Hair transplant is among the most common cosmetic services sought by men, with more than 11 000 procedures performed in 2014. Despite its growing popularity, the effect of hair transplant on societal perceptions of youth, attractiveness, or facets of workplace and social success is unknown.
Objectives
To determine whether hair transplant improves observer ratings of age, attractiveness, successfulness, and approachability in men treated for androgenetic alopecia and to quantify the effect of hair transplant on each of these domains.
Design, Setting, and Participants
A randomized controlled experiment was conducted from November 10 to December 6, 2015, using web-based surveys featuring photographs of men before and after hair transplant. One hundred twenty-two participants recruited through various social media platforms successfully completed the survey. Observers were shown 2 side-by-side images of each man and asked to compare the image on the left with the one on the right. Of 13 pairs of images displayed, 7 men had undergone a hair transplant procedure and 6 had served as controls. Observers evaluated each photograph using various metrics, including age, attractiveness, successfulness, and approachability. A multivariate analysis of variance was performed to understand the effect of hair transplant on observer perceptions. Planned posthypothesis testing was used to identify which variables changed significantly as a result of the transplant.
Main Outcomes and Measures
Observer ratings of age (in number of years younger) and attractiveness, successfulness, and approachability (on a scale of 0 to 100; scores higher than 50 indicate a positive change).
Results
Of the 122 participants in the survey, 58 were men (47.5%); mean (range) age was 27.1 (18-52) years. The initial multivariate analysis of variance revealed a statistically significant multivariate effect for transplant (Wilks λ = 0.9646; P < .001). Planned posthypothesis analyses were performed to examine individual differences across the 4 domains. Findings determined with t tests showed a significant positive effect of hair transplant on observers’ perceptions of age (mean [SD] number of years younger, 3.6 [2.9] years; P < .001), attractiveness (mean [SD] score, 58.5 [17.5]; P < .001), successfulness (mean [SD] score, 57.1 [17.1]; P = .008), and approachability (mean [SD] score, 59.2 [18.1]; P = .02).
Conclusions and Relevance
Men were perceived as being younger and more attractive by casual observers after undergoing hair transplant. Participants also rated posttransplant faces as appearing more successful and approachable relative to their pretransplant counterparts. These aspects have been shown to play a substantial role in both workplace and social success, and these data demonstrate that hair transplant can improve ratings universally across all 4 domains.
Level of Evidence
NA.
Androgenetic alopecia (AGA) is a genetically determined progressive hair-loss condition which represents the most common cause of hair loss in men. The use of the medical term androgenetic alopecia reflects current knowledge about the important role of androgens and genetic factors in its etiology. In addition to androgen-dependent changes in the hair cycle, sustained microscopic follicular inflammation contributes to its onset. Furthermore, Prostaglandins have been demonstrated to have the ability in modulating hair follicle cycle; in particular, PGD2 inhibits hair growth while PGE2/F2a promote growth. Due to the progressive nature of AGA, the treatment should be started early and continued indefinitely, since the benefit will not be maintained upon ceasing therapy. To date, only two therapeutic agents have been approved by the Food and Drug Administration and European Medicines Agency for the treatment of AGA: topical minoxidil and oral finasteride. Considering the many pathogenetic mechanisms involved in AGA, various treatment options are available: topical and systemic drugs may be used and the choice depends on various factors including grading of AGA, patients' pathological conditions, practicability, costs and risks. So, the treatment for AGA should be based on personalized therapy and targeted at the different pathophysiological aspects of AGA.
Follicular unit extraction (FUE) has been performed for over a decade. Our experience in the patients who underwent hair transplantation using only the FUE method was included in this study.
A total of 1000 patients had hair transplantation using the FUE method between 2005 and 2014 in our clinic.
Manual punch was used in 32 and micromotor was used in 968 patients for graft harvesting. During the time that manual punch was used for graft harvesting, 1000-2000 grafts were transplanted in one session in 6-8 h. Following micromotor use, the average graft count was increased to 2500 and the operation time remained unchanged. Graft take was difficult in 11.1 %, easy in 52.2 %, and very easy in 36.7 % of our patients.
The main purpose of hair transplantation is to restore the hair loss. During the process, obtaining a natural appearance and adequate hair intensity is important. In the FUE method, grafts can be taken without changing their natural structure, there is no need for magnification, and the grafts can be transplanted directly without using any other processes. Because there is no suture in the FUE method, patients do not experience these incision site problems and scar formation. The FUE method enables us to achieve a natural appearance with less morbidity.
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 .
Finasteride is standard medical treatment for androgenetic alopecia; however, no large studies with 5 years or more of follow up have been performed in Japan. The authors followed Japanese men with androgenetic alopecia treated with finasteride for 5 years to evaluate long-term treatment efficacy. Of 903 men treated with finasteride (1 mg/day), 801 patients were evaluated over 5 years by modified global photographic assessment. Although the proportion of improvement was high (99.4%), modified global photographic assessment scores after 5 years of treatment were lower in patients with more advanced disease as measured by the modified Norwood-Hamilton scale. After separating patients into "sufficient" and "insufficient" efficacy groups according to the modified global photographic assessment score after 5 years (scores ≥6 and <6, respectively), multivariate analysis showed that independent risk factors of insufficient efficacy were age at start of treatment of 40 years or more (P = 0.021) and classification on the modified Norwood-Hamilton scale (P < 0.001), whereas presence of stress at start of treatment was a negative predictor (P = 0.025). In conclusion, continuous finasteride treatment for 5 years improved androgenetic alopecia with sustained effect among Japanese. Younger age and less advanced disease at start of treatment were the key predictors of higher finasteride efficacy.
© 2015 Japanese Dermatological Association.
For many hair restoration patients with limited scalp donor hair it is possible to use nonhead hair sources to increase the potential follicle supply. Follicular unit extraction provides the hair restoration surgeon with a useful surgical means for accessing this valuable source of donor reserve. Nonhead hair can also be used to restore eyebrows, eyelashes, and moustaches. This article focuses on the use of body hair and beard in hair restoration. Discussed are the indications and effective techniques for performing hair transplants using non head hair donor sources, along with the pitfalls and risks of this surgical modality.
Surgical hair restoration allows male and female patients to achieve aesthetically natural results. The term megasession refers to transplanting greater then 3000 follicular unit grafts in a single procedure. By transplanting a large number of grafts, megasessions are capable of definitively treating a significant area of the scalp in 1 session. Patients must be carefully selected to determine whether they are appropriate candidates for an extended procedure. An experienced and well-organized surgical team is mandatory to meet the demands of this technically challenging and lengthy procedure. This article reviews the indications, contraindications, and technical perspectives surrounding megasession hair transplantation.
Pattern hair loss (PHL) is the most common form of baldness in both sexes. The Norwood-Hamilton classification is the most commonly used classification worldwide, but it has many limitations. The basic and specific (BASP) classification was introduced as an improvement over the Norwood-Hamilton classification. Previous research was done to estimate the reliability of the Norwood-Hamilton classification and the result was unsatisfactory. However, the reliability of the BASP and Norwood-Hamilton classifications has not yet been compared. Eight dermatological specialists, 17 dermatological residents and 15 general physicians classified PHL in 100 sets of photographs using both the BASP and Norwood-Hamilton classifications. Intergroup reproducibility was evaluated by examining the match rate of the individual data in each group and the match rate between hair specialist and the other examiners. Intragroup repeatability was determined by calculating the match rate between the first and second studies. In terms of intergroup reproducibility of the match rate for individual data in each group, the basic type had the best agreement, the specific type had the second best, and the Norwood-Hamilton classification had the lowest match rate. In comparison, hair specialist and intragroup repeatability showed the same patterns. The BASP classification not only distinguishes all kinds of hair loss patterns, but also has better reproducibility and repeatability than the Norwood-Hamilton classification.
The field of hair transplantation has evolved considerably over the last quarter century. Performed correctly, the cosmetic results of contemporary hair transplantation are virtually undetectable in women and men. Large, pluggy "punch grafts" have been replaced with natural-appearing follicular unit grafts, which maintain their existing anatomy and with proper technique can match the orientation of surrounding hair follicles.
To review all of the steps involved in hair transplantation surgery and to provide an overview of medications used in conjunction with transplantation to help prevent hair loss.
The authors review key aspects of the consultation, physical examination, selection of appropriate candidates, excision of donor area, hairline design, graft creation and placement, and postoperative instructions. The role of medications such as minoxidil and finasteride in preventing ongoing hair loss is an essential part of the treatment plan. For nonsurgical candidates, other treatments such as wigs, hairpieces, and camouflages are reviewed. Future trends may involve the use of low-level laser light therapy, dutasteride, and cloning of follicles.
Patients and physicians alike are pleased with the results of contemporary hair transplantation, and physicians can now recommend the procedure without reservation. The authors have indicated no significant interest with commercial supporters.
Follicular unit transplantation (FUT) is the culmination of decades of refinement and evolution of hair transplantation techniques. Hair naturally grows in groups of one to four individual follicles separated by intervening soft tissue. These clumps or groups of hairs are termed FOLLICULAR UNITS. FUT uses microscopic dissection to separate these units for transplantation in a fashion that most closely resembles naturally occurring hair. FUT has grown to become recognized by many prominent hair restoration surgeons as the state-of-the-art method of hair replacement surgery for both male and female pattern alopecia. Although larger punch grafts, scalp flaps, and alopecia reductions may play a role in certain cases, FUT achieves results that are difficult to differentiate from naturally occurring hair. The central attributes of the technique are the provision of natural-appearing hairlines with reasonable density together with low morbidity and minimal "downtime." Nevertheless, the technique is only as effective as the technician, and results are heavily dependent on the forethought of the architect.
Skin and hair colour mostly depend on the activity of melanogenic melanocytes. Numerous proteins involved in melanocyte function have been identified including pMel-17, Mitf-M, Sox10, tyrosinase, tyrosinase related proteins-1 (TRP-1) and -2 (TRP-2). In the hair, melanogenic activity occurs only during the anagen phase of the hair cycle. In order to evaluate the implications of some known melanogenic proteins in human hair pigmentation, we performed immunohistochemical studies to reveal the expression of pMel-17, Mitf-M, tyrosinase, TRP-1 and TRP-2 in active bulb melanocytes of eumelanic brown and black anagen hairs of different ethnic origins, e.g. brown Caucasian, black Asian and African hairs. The labelling was compared with that observed in Caucasian and African scalp epidermis (interfollicular epidermis) melanocytes. We found that while pMel-17, TRP-1 and TRP-2 were expressed in epidermal melanocytes irrespective of ethnic origin and melanin content of the scalp epidermis, Mitf-M and tyrosinase expression were clearly evidenced only in pigmented epidermis, e.g. African scalps. Regarding human hair, pMel-17, Mitf-M, tyrosinase and TRP-1 were detected in a similar manner in active bulb melanocytes of brown and black hairs. In contrast and unexpectedly, TRP-2 could not be detected in hair bulb melanocytes, whatever the hair colour and ethnic origin. The lack of TRP-2 was further confirmed by western blot analyses. Reverse transcriptase-polymerase chain reaction (RT-PCR) performed on hair bulb mRNA demonstrated that Mitf-M, tyrosinase and TRP-1 amplimer signals were easily detected, whereas the TRP-2 amplimer signal was barely detectable. Furthermore Sox10 was not detected in hair bulb. Altogether our results suggest that the absence of detectable level of TRP-2 is due to transcriptional control in active melanocytes of human eumelanic hair bulbs. According to the absence of TRP-2 in melanin-producing melanocytes of brown and black hair bulbs, one must consider that eumelanogenesis as well as brown and black colour do not require TRP-2 expression in human hair.
Pattern hair loss (PHL) can be classified into several patterns. Currently, the Hamilton-Norwood classification system for men and the Ludwig grade system for women are commonly used to describe patterns of hair loss. However, these pre-existing classifications have some limitations.
To establish an acceptable, universal, and accurate standard of both male and female pattern hair loss and to report its use in determining the incidence of PHL.
We developed a new classification system (BASP classification) and then applied this system to classify the types of PHL. The BASP classification was based on observed patterns of hair loss. The basic (BA) types represent the shape of the anterior hairline, and the specific types (SP) represent the density of hair on distinct areas (frontal and vertex). There are four basic types (L, M, C, and U) and two specific types (F and V). The final type is decided by the combination of the assigned basic and specific types. Between November 2004 and June 2005, 2213 Korean subjects, comprised of 1768 males and 445 females, were classified according to the BASP classification at 13 university dermatologic centers nationwide throughout South Korea, as a multicenter study of the Korean Hair Research Society.
For both sexes, the majority of patients enrolled in the study were in the third and fourth decade of life (65.1% of males and 56.68% of females). In males, the older group as well as the younger group in the study were more likely to have little recession of the frontal hairline (classified as type M1 approximately 2) and diffuse thinning over the top of scalp (type F1 approximately 2). The women in the study developed typical female PHL.
The subjects of our study were mostly outpatients and some inpatients who complained about hair loss, not the general population of Korea.
The BASP classification is a new stepwise, systematic, and universal classification system for PHL, regardless of sex.
Hair morphology differs dramatically between human populations: people of East Asian ancestry typically have a coarse hair texture, with individual fibers being straight, of large diameter, and cylindrical when compared to hair of European or African origin. Ectodysplasin-A receptor (EDAR) is a cell surface receptor of the tumor necrosis factor receptor (TNFR) family involved in the development of hair follicles, teeth, and sweat glands. Analyses of genome-wide polymorphism data from multiple human populations suggest that EDAR experienced strong positive selection in East Asians. It is likely that a nonsynonymous SNP in EDAR, rs3827760, was the direct target of selection as the derived p.Val370Ala variant is seen at high frequencies in populations of East Asian and Native American origin but is essentially absent from European and African populations. Here we demonstrate that the derived EDAR370A common in East Asia has a more potent signaling output than the ancestral EDAR370 V in vitro. We show that elevation of Edar activity in transgenic mice converts their hair phenotype to the typical East Asian morphology. The coat texture becomes coarse, with straightening and thickening of individual hairs and conversion of fiber cross-sectional profile to a circular form. These thick hair fibers are produced by enlarged hair follicles, which in turn develop from enlarged embryonic organ primordia. This work shows that the multiple differences in hair form between East Asian and other human populations can be explained by the simplest of genetic alterations.
Follicular unit excision is one of the methods for hair follicle harvesting in hair transplantation. Fue involves harvesting hairs from the donor area, donor harvesting: follicular unit excision
- Garg A
Follicular unit extraction fue is becoming an increasingly popular method for hair restoration. as fue leaves behind no linear scars, body to scalp: evolving trends in body hair transplantation
- Saxena K
Multi‐therapies in androgenetic alopecia: review and clinical experiences
- A Rossi
- A Anzalone
- MC Fortuna
The field of hair transplantation has evolved considerably over the last quarter century. performed correctly, contemporary hair transplantation
- Avram M
Multi‐therapies in androgenetic alopecia: review and clinical experiences
- Rossi A
Megasessions ‐ Evolution of a Technique. Hair Transplant Forum
- Bernstein RM