Hair Transplantation Procedures Research Articles

The Proportion of Catagen and Telogen Hair Follicles in Occipital Scalp of Male Androgenetic Alopecia Patients: Challenging the Established Dogma.

The hair follicle can cycle throughout a lifetime, undergoing periods of growth (anagen), regression (catagen) and relative quiescence (telogen). The time that a hair follicle spends in each of these stages is crucial to determine the length of hair fibre that it produces. Perturbations in this regard can manifest in various hair diseases such as anagen effluvium, or acute and chronic telogen effluvium. The established 'dogma' when considering how many hair follicles there are in each stage has long been that the majority are in anagen (85%-90%), followed by telogen (10%-15%) and catagen (1%-2%). These values are based on various studies using different methodologies such as hair plucking, phototrichograms and histology. However, these methods have flaws when it comes to differentiating between catagen and telogen follicles. We sought to determine the catagen: telogen ratio through the exvivo stereomicroscopic examination of hundreds of hair follicles removed from the occipital scalp of 14 Caucasian males during routine hair transplantation procedures. Using this methodology, and in agreement with a similar observation by another research group, we found that the percentage of catagen hair follicles was higher (7.5%) than telogen (3.5%) in all patients assessed. Consequently, we believe that the percentage of catagen follicles is clearly underestimated and therefore challenge the current established dogma.

Hair Transplantation on the Baldness Region with Free Latissimus Dorsi Flap for Scalp Reconstruction: A Case Report

AbstractScalp reconstruction, particularly with complex defects and infection risks, often favors microvascular free flaps. However, this method can result in unavoidable alopecia and undesirable aesthetics. This report describes a novel case where hair transplantation via follicular unit extraction (FUE) was applied to a free myocutaneous flap. A 44-year-old woman with Moyamoya disease suffered intracerebral hemorrhage a decade ago. Craniotomies and autologous bone cranioplasties led to wound dehiscence, with subsequent failed local flaps and skin grafts, and identification of a methicillin-resistant Staphylococcus aureus infection. The final scalp defect, measuring 13 × 9 cm, was reconstructed using a free myocutaneous latissimus dorsi flap. Nine years post-surgery, a 1,500-unit FUE hair transplantation procedure was conducted. The transplanted hair exhibited robust survival with adequate blood supply, achieving a satisfactory 80 to 85% survival rate at 12 months. This resulted in a notable improvement in the patient's external alopecia, with reported high levels of satisfaction. Free flaps offer a valuable method for scalp defect reconstruction; however, they may not ensure optimal aesthetic satisfaction due to alopecia. Nonetheless, successful FUE hair transplantation on a myocutaneous free flap can yield satisfactory aesthetic results.

Hair Transplant Follicular Unit Extraction Technique as a Current Treatment Option for Androgenetic Alopecia

The therapy for androgenetic alopecia currently varies, and there is no generally efficacious form of treatment. Despite receiving therapy, a portion of individuals with alopecia still do not achieve the anticipated hair regrowth outcomes. The absence of efficacious medical intervention typically necessitates the exploration of alternative therapy modalities. A significant number of patients who do not get satisfactory results from medical treatment explore other therapeutic approaches, such as hair transplantation. Advancements in hair transplantation procedures have seen substantial progress since the 1960s. Men frequently seek hair transplantation, making it a popular cosmetic treatment. Over 11,000 operations took place in the United States in 2014. Commonly practiced contemporary hair transplant procedures include follicular unit transplantation (FUT) and follicular unit extraction (FUE). The FUE technique is gaining popularity due to its non-invasive nature, quicker recovery time, reduced post-operative discomfort, and fewer surgical scars, in contrast to the FUT approach.

Complications with Follicular Unit Excision.

Hair restoration surgery (HRS) is typically a safe outpatient or office-based procedure when physicians follow high ethical standards and uphold community practice standards. Patients' clinical outcomes are mostly operator dependent, and temporary and permanent complications rarely occur. Follicular unit excision (FUE) donor harvesting, in particular, is a challenging harvesting technique requiring a long learning curve, physical stamina, higher than average hand-eye coordination and manual dexterity. The types of complications associated with FUE are comparable to linear strip excision (LSE). Similar to LSE donor harvesting, FUE complications may occur irrespective if standard precautions are followed by the physician. As in any skin and scalp procedure, injuries and poor cosmetic outcomes occur despite appropriate preoperative precautions and intraoperative technique. In increasing and greater instances, however, FUE complications are observed when the physician fails to follow hair restoration practice standards and routine surgical precautions. Physician induced, or iatrogenic complications occur more often when untrained licensed surgeons perform HRS, and who fail to meet practice standards and best practices. In the last decade, physician-influenced FUE complications, or iatrogenic cause of FUE injuries are increasingly observed which results in poor aesthetic outcomes. Higher than average FUE complication rates occur in cases involving inadequately trained physicians, as well as in cases where improper delegation of the FUE hair transplant procedure is performed by unlicensed and untrained individuals. In this chapter, we described commonly encountered HRS complications, as well as physician influenced, or iatrogenic causes of FUE complications.

Instrumentation and Devices Specific to Follicular Unit Excision.

The volume of hair transplantation procedures done via the follicular unit excision (FUE) harvesting technique has increased tremendously over the last few years. With this growth, new advances in technology have come along. The wide variety of instrumentation and devices can be overwhelming, especially for a novice surgeon. This chapter aims to discuss the relevant aspects of FUE and its relationship to the devices that are used to harvest grafts. The development and overview of all the major types of instrumentation will be reviewed.

Design, proof-of-concept of single robotic hair transplant mechanisms for both harvest and implant of hair grafts

The design and development of a prototype for a singular robotic hair transplant system capable of harvesting and implanting hair grafts were executed in this study. To establish a proof-of-concept for hair transplant procedures involving harvesting and implantation, a test system using a spherical phantom of the scalp was selected. The developed prototype of the robotic hair transplant system demonstrates the potential to reduce the duration that grafts remain without a blood supply, thereby minimizing hair graft damage. Additionally, the overall operation time for follicular unit extraction is comparatively shorter than that of conventional systems. Results from the robot vision tests indicate an 89.6% accuracy for hair graft detection with a 4 mm hair length phantom and 97.4% for a 2 mm hair length phantom. In the robot position control test, the root mean square error was found to be 1.268°, with a standard error of the mean of 0.203°. These outcomes suggest that the proposed system performs effectively under the conditions of a spherical phantom with a 2 mm hair length and a 5 mm distance between harvests.

Follicular Unit Excision (FUE) Basics.

Follicular unit excision (FUE) has risen to the forefront as the world's most popular hair transplant procedure. However, most writing on this subject has catered to the advanced practitioner. The goal of this article will be to focus on safe planning and decision making along with key technical steps that will guide the beginner surgeon to harvest a graft safely and to harvest the donor area in a uniform way to avoid overharvesting. Topics covered in this article also include instrumentation and decision making between FUE versus linear strip excision.

PRECISE Scale: a quantitative classification for androgenetic alopecia and its application to hair transplantation

BackgroundAndrogenetic alopecia (AGA) is a prevalent genetic condition that can affect both male and female, and is considered the most frequent form of hair loss. Traditional scales and methods of classifying AGA are basically qualitative.ObjectiveThis work aims to propose a quantitative scale to classify AGA in order to assist hair transplantation surgery.MethodsBased on whole hairless and thinning areas that needs to receive follicular units in a hair transplantation procedure, basic equations to support the scale are proposed. Additionally, the study involves simulations that apply the classification system and compare its results with those of qualitative methods.ResultsThe PRECISE scale utilizes a range of 0–10, using 30 cm2 as the measured standard of a bald area. For hair transplantation, 1500 follicular units (FU) are recommended for each score in the PRECISE scale. Technological and manual methods to measure the hairless and thinning areas are presented and discussed. This new quantitative classification, combined with different and complementary methods of measurement of hairless and thinning areas endorse the understanding of the clinical condition by the patient and the planning of a surgery procedure.ConclusionThe developed PRECISE scale brings a different way of classifying Androgenetic alopecia (AGA), through an essentially quantitative evaluation. It can be used to elaborate the best strategy for the hair transplantation surgery and to improve the outcomes.Level of Evidence VThis 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.

Complications and Difficult Cases

![Figure][1]</img> In 2014, in this same column, I described a patient of mine who had a hair transplant procedure with me in 2013 to cover an area of his scalp that was alopecie due to radiation therapy for the treatment of a meningioma, which had been excised prior to the radiation treatment, in

Encountering steroid treatment induced tinea incognito: a case report

Tinea incognito refers to a type of dermatophyte infection that affects the skin, and its signs and symptoms upon presentation tend to appear permutated due to the prior use of immunosuppressants, corticosteroids or calcineurin inhibitors. We present a 42-year-old Asian (Indian) male patient with scaly erythematous rashes, mimicking annular erythema, and developing post-corticosteroid usage after an elective hair transplant procedure. The results of the biopsy reported that erythema annulare centrifugum (EAC) was absent, and the sample was suggestive of potential infective folliculitis. By day 3 of the presentation, with fungal stain tested positive for the presence of fungal infection. Based on this, the final diagnosis of tinea incognito was made. The final treatment prescribed for tinea incognito was an anti-fungal tablet of Itraconazole at a dose of 100 mg twice a day for 4 weeks, topical luliconazole, ciclopirox and anti-histamines for itching. Topical corticosteroids can change the clinical appearance of tinea by reducing erythema and scaling while enabling the fungus to grow freely without presenting the typical clinical indications of tinea. Practitioners should follow patients on corticosteroid treatment to alert them to potential cutaneous problems due to possible fungal infections, whenever warranted.

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

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

The Expansion of Turkey’s Medical Tourism Industry

The Expansion of Turkey’s Medical Tourism Industry

A New Universal Follicular Unit Excision Classification System for Hair Transplantation Difficulty and Patient Outcome.

IntroductionThe difficulty of the follicular unit excision (FUE) hair transplantation procedure is currently attributed to hair curliness and subsurface angulation. Patients possessing the curliest hair shafts are considered the most challenging. Consequently, patients with these features are often denied FUE. However, this practice does not consider intrapatient variation in the graft attrition rate and the rates themselves, which are frequently low in very curly hair where the skin firmness/thickness is average. To better aid practitioners in predicting FUE performance, we have developed a new scoring system (the Sanusi FUE Score Scale [SFS Scale]) based on two major donor variables (hair and skin characteristics).Material and MethodThe scale assigns scores to each of three hair subtypes (straight-wavy, curly, and coily-kinky) and each of three skin subtypes (thick/firm, soft/thin, and medium thickness/firmness). The scores were weighted based on the assessment of 13 experienced FUE practitioners from around the globe, who were asked to score each of the three skin and hair characteristics for their contribution to FUE difficulty.ResultsOn the contribution of skin characteristics to FUE difficulty, 12/13 (92%) practitioners assigned the highest (most difficult) score to thick/firm skin, with medium skin thickness/firmness being the least challenging. The same percentage of practitioners gave the highest difficulty score to coiled-kinky hair subtypes regarding the contribution of hair characteristics to FUE difficulty. All agreed that straight-wavy hair presents the least challenge to FUE performance. Tallying the scores of the skin and hair variables generates a final score range of 2–9, which is associated with five grades/classes of challenge in the FUE procedure, influencing the need for a specialized skill/nuanced approach or equipment.ConclusionWe developed a universal FUE donor scoring scale that accounts for the diversity of human hair and skin types. Further evaluation to determine the validity of this new classification system in predicting and grading FUE difficulty and patient outcomes is warranted.

Aesthetic Importance of the Parietal Eminence Area (Posterior Parietal Triangle), an Essential Island of Scalp Requiring Hair Restoration

<i><b>Introduction:</b></i> Hair loss is a progressive disorder that if not treated in the early stages may lead to baldness, requiring a hair transplantation. Hair restoration of the frontal area of the scalp, followed by mid-scalp and vertex, is the usual order of priority for hair transplantation. Because of the progressive nature of hair loss, patients who undergo hair transplantation in the frontal and mid-scalp may later show prominent bald scalp in the parietal eminence area (posterior parietal triangle). This thinning in the parietal eminence is noticeable in frontal lateral profile views, which can be concerning to the patient. The parietal eminence, or posterior parietal triangle, is part of the vertex/crown, and the vertex is the last priority of scalp hair restoration. However, to maintain the patient’s aesthetic appearance, we feel the parietal eminence area should be covered when implanting the mid-scalp. <i><b>Method:</b></i> We examined our patients who underwent hair transplant in the frontal and mid-scalp areas. Some showed thinning and/or baldness in the parietal eminence area, which was readily visible in the patients’ lateral profile and frontal view. We concluded that the parietal eminence area is an essential aesthetic area of the scalp and therefore should be treated as an extension of the mid-scalp area. Based on this, we modified how we transplanted the mid-scalp. The mid-scalp area was extended to both sides to include the parietal eminence (posterior triangle) area. The transplanted hair in the parietal eminence area shadows the central vertex area. <i><b>Results:</b></i> The patients who underwent hair transplant procedures to cover the frontal and mid-scalp along with the parietal eminence area showed good hair coverage and were happy on follow-up. <i><b>Conclusion:</b></i> Hair transplant of the parietal eminence is an underappreciated means to maintain balance in the frontal and lateral profiles and restore the head’s contours. In limited donor availability, when the vertex is not transplanted, preferential attention to parietal eminence can provide indirect cosmetic benefit to the vertex.

The Progressive Loss Risk Scale for Hair Restoration Surgery.

Limited information exists on the long-term risks to individuals undergoing procedures in hair restoration surgery. The short-term risks are well known and similar to other procedures in dermatologic surgery. The long-term risks of hair restoration surgery are seldom discussed between the physician and patient. The author sought to describe a classification system that can be used as a communication tool between physicians and patients to define the long-term risk involved with hair restoration surgery. The Progressive Loss (PL) Scale is an attempt at assessing the cosmesis because of future hair loss following a hair transplant procedure. The PL Risk Scale has designated 5 levels, 1 to 5, with each ascending level representing a higher level of risk. The PL Risk Scale can be assigned to an individual at the time of the assessment for hair restoration surgery. Each patient can be assigned a risk level based on how future hair loss may affect the overall cosmetic result of their hair transplant. This risk is dependent on age, and specific for the area to be transplanted. The younger the age of the patient, the higher the risk. The larger the area to be transplanted, the higher the risk. It is not a static scale, because it will be affected by age, donor area, location of transplantation, and other mitigating factors. Pattern baldness in men and women is progressive and unrelenting. The dichotomy of hair restoration surgery is that a satisfactory short-term outcome can evolve to disappointing results because of progressive hair loss. The PL Risk Scale can be assigned to every individual undergoing a hair restoration procedure. This scale assignment will convey to the patient their lifetime risk associated with any given surgical hair restoration procedure for that age and the specific area to be restored.

Chronologic improvement in hair yield with follicular unit excision with changes in punch devices: A 10-year experience of a single center.

Follicular unit excision (FUE), which is a newer hair transplant procedure was thought to be only usable in limited areas at the beginning. However, it is the most preferred technique these days. It is known transection rates have decreased with punch technology (and experience) over the years. We analyzed the data from so-so many male patients who underwent hair transplantation by FUE method at our clinic retrospectively to elucidate how the development of punch technology affected the number of total grafts and FU containing multiple hairs. Between the years 2011 and 2020, male hair transplant patients operated with the FUE method at the author's dermatology clinic, was investigated retrospectively. Overall 1415 cases were included in the study. Total graft numbers and 1-4 hair FUs were calculated. There was a statistically significant difference in terms of number of total grafts, one hair follicular unit (I FU) three hair follicular unit (III FU) distributions according to operation year and punch type (p < 0.05). The serrated punch resulted in a significant increase in the numbers of total grafts and the trumpet punch resulted in a significant increase in the number of 3FU grafts. Our study has shown that hair yield has been increased with new punch technologies. With an increasing hair yield by the aid of evolving punch technology, hair transplantation with the FUE method has become the first choice for hair transplantation preferred by both doctors and patients.

How to manage intra-operative slippery grafts

Hair transplant procedures can last many hours, starting from the preoperative assessment, hairline placement, careful donor harvesting, slivering, graft cutting, and, finally, insertion. In the era of mega sessions and giga sessions, a procedure can last 8-11 hours. Most hair transplant physicians

Need for Regulation of Medical Practice (Hair Transplantation) in India: Delhi High Court

This case went before Delhi High Court after the death of a patient who had undergone hair transplant, suffered serious complications. Various medico-legal and ethical issues emerged and need to be felt for the National Protocol for hair transplant in India, as procedure is unregulated by statute, even in Capital of India, Delhi exposing the issue of patient safety. Delhi High Court observed that hair transplantation being an aesthetic surgery needs to be performed by qualified dermatologists or trained surgeons with informed consent of the patient. It is critical to evaluate the risk benefit ratio from the medical perspective. It is imperative on the persons performing the transplantation surgery to be aware of the medico legal issues. Present matter has larger ramifications as number of such treatment Salons are mushrooming, wherein the self-proclaimed technicians are rendering the service of hair transplantation/aesthetic surgery which is completely in teeth of medical ethics and in defiance of standard protocol to be followed for the purpose of hair transplantation/ aesthetic surgery. It appears that in the present case, neither there was informed consent of the deceased, nor the risk involved in the hair transplantation was disclosed to the deceased, which resulted in acute complications finally resulting in the death of the deceased. The case also highlights the issues of medical negligence as well as medical malpractice which continue for want of any check of such Salons by the competent authorities. There is a need for creating awareness among all stakeholders to avoid future deaths in such cases. Concerned government authorities should frame national protocol for hair transplant procedure.

Complications of Hair Transplant Procedures-Causes and Management.

Hair transplant surgery per se has low risk, is relatively safe, and has minimum incidence of complications. However, it is a well-accepted fact that no medical science procedure exists without any potential risk of complications. The complication may be a single complaint in the form of pain, itching, dissatisfaction related to the procedure's outcome, or surgical complication in the form of infection, wound dehiscence or skin necrosis. Inadequate counselling increases unsatisfaction. Improper examination increases the complications, and incomplete medical history and history of allergy increases the risk during surgery.The author collected data of his 2896 patients, operated over a period of 10 years, and recorded the complains and complications. The most common complications were sterile folliculitis, noted in 203 patients, vasovagal shock in seven patients of, hypertensive crisis in one patient, hiccups in six patients, facial edema after hair transplant in 18 patients, graft dislodgement in 8 patients, infection in two diabetic patients, minor necrotic patches in recipient area in three patients, keloid development in one patient, numbness in 18 cases, and hypersensitivity in recipient and/or donor area. Donor area effluvium was seen in one case and three patients showed recipient area effluvium. Twenty-six patients were not happy with the results, and five cases showed partial loss of implanted hair. The overall significant life-threatening or major complications were zero, but the total minor complications' percentage was 0.10%.The key to minimize complaints and complications are detailed counselling, taking careful medical history and history of allergy, and proper examination of patients.

One-Month Trial of HOCl: An Observational Pilot Study

The search for a clearly superior aid to wound healing that meets the unique needs of the hair transplant surgeon has been fraught with frustration and littered with failed attempts.^1,2 Hydrogen peroxide, chlorhexidine, isopropyl alcohol, and betadine have been used for their antibacterial properties.^2,3 Copper peptide, silicone, hydrocolloid, and others have been used for their accelerative healing properties with mixed results. As of 2007 hypochlorous acid (HOCl), which has both antibacterial and wound healing properties, had never been used as a pharmaceutical drug, and as of 2021, it has not been described in the literature specific to hair transplant procedures. We investigated the use of medical grade HOCl as a routine component of both intra-operative hair transplant procedures (both linear excision and follicular unit excision) and as a post-operative wound healing aid.