Hair Transplantation Controversies Marc R. Avram, MD,*† Robert Finney, MD,‡ and Nicole Rogers, MDxk BACKGROUND Hair transplant surgery creates consistently natural appearing transplanted hair for men. It is increasingly popular procedure to restore natural growing hair for men with hair loss. OBJECTIVE To review some current controversies in hair transplant surgery. MATERIALS AND METHODS plant surgery. Review of the English PubMed literature and specialty literature in hair trans- RESULTS Some of the controversies in hair transplant surgery include appropriate donor harvesting technique including elliptical donor harvesting versus follicular unit extraction whether manual versus robotic, the role of platelet-rich plasma and low-level light surgery in hair transplant surgery. CONCLUSION Hair transplant surgery creates consistently natural appearing hair. As with all techniques, there are controversies regarding the optimal method for performing the procedure. Some of the current controversies in hair transplant surgery include optimal donor harvesting techniques, elliptical donor harvesting versus follicular unit extraction, the role of low-level light therapy and the platelet-rich plasma therapy in the procedure. Future studies will further clarify their role in the procedure. The authors have indicated no significant interest with commercial supporters. M.R. Avram is an unpaid consultant for Restoration Probotics. O ver the past 20 years, the cosmetic standard for hair transplantation has been the ability to consistently create natural appearing transplanted hair for men (Figures 1 and 2). The procedure is performed as an outpatient with local anesthesia with a low rate of medical and surgical complications. As with all surgical procedures, there has been a continual evolution in technique with the goal of an ever more efﬁcient, safer, and even higher level of patient satisfaction. This article will review several of the most salient debates in the ﬁeld of hair transplantations. As with all procedures, the consult is vital to establish candidate selection. Patients with increased donor density, thick-caliber hair follicles, and areas of clear thinning in the frontal scalp are ideal candidates for the procedure. Those with limited donor density and ﬁne thin-caliber hair follicles will have less cosmetic impact from a procedure. It is vital that patients understand the ongoing nature of male-pattern hair loss and how that will impact the perceived density and cosmetic appearance of a transplant. Transplanting the frontal half, the scalp is considered the cosmetically safe zone where ongoing hair loss will impact the perceived density of a transplant but not the natural appearance of the procedure. Transplanting the vertex of the scalp does have more long-term cosmetic risk with an unnatural “doughnut” appearance of hair. Successful medical therapy to stabilize male-pattern hair loss should be discussed with all patients with existing pigmented terminal hair considering a hair transplant to create optimal long-term density. Age is not a determining factor in candidate selection. Expectations, short- and long-term planning of where to transplant and not transplant is the key. Younger patients have greater risk of long-term widespread hair *Private Practice, Dermatology, New York, New York; †Weill Cornell Medical Center, New York, New York; ‡Heights Dermatology, Brooklyn, New York; xTulane Health Sciences Center, New Orleans, Louisiana; kPrivate Practice, Old Metairie Dermatology, Metairie, Louisiana © 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 1076-0512 Dermatol Surg 2017;43:S158–S162 DOI: 10.1097/DSS.0000000000001316 · · S158 © 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. AVRAM ET AL Ellipse Versus Follicular Unit Extraction Figure 1. Before hair transplantation. loss and therefore must understand what can and cannot be accomplished with a hair transplant. If a patient has realistic short- and long-term expectations, they are potential candidates for the procedure. Donor Harvesting The day of the procedure, informed written consent is obtained (consent given before the procedure for the patient to review), and wound care instructions and activities are reviewed. The area to be transplanted is marked off by the physician, and photographs are taken. Patients are encouraged to bring food and drinks to the procedure and ask for breaks to eat, drink, or check their emails during the procedure. The goal is to have a relaxed, comfortable patient. Currently, there are 2 techniques for removing donor hair: elliptical donor harvesting and follicular unit extraction (FUE). Elliptical donor harvesting has been performed for over 20 years.1 It is performed under local anesthesia. The length and width of the ellipse depends on whether hundreds or thousands of follicular units from the posterior scalp are needed to be transplanted in the frontal scalp. The ellipse is separated by skilled surgical assistants into individual follicular units. Follicular unit extraction is the direct removal of individual follicular units using 0.8- to 1.2-mm manual punches, mechanically assisted devices, or robotically.2–5 With FUE surgery, the entire posterior scalp is trimmed to 1 mm. This is mandatory to allow the harvesting of individual follicular units using 0.8- to 1.1-mm punches (Figure 3). There is an intense debate as to which technique is superior. Advocates of elliptical donor harvesting believe that there is a lower transection rate of follicular units resulting in greater growth of transplanted hair. Advocates of FUE tout the minimally invasive aspect of obtaining follicular units, absence of a long linear scar, and no need for sutures results in better wound healing. In addition, FUE mimics the trend in medicine toward minimal invasive surgery. The donor harvesting is performed using local anesthesia such as lidocaine with epinephrine. Patients are in the prone position for harvesting the grafts from the posterior scalp. Currently, both techniques should be considered state of the art in hair transplantation. Both techniques should be discussed during a hair transplant consult. Each Figure 2. After 1,100 grafts, 1 procedure. Figure 3. Harvested follicular units measuring 0.9 mm in diameter. 43:11S:NOVEMBER SPECIAL ISSUE 2017 S159 © 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. HAIR TRANSPLANTATION CONTROVERSIES technique has potential advantages for the individual patient (Table 1). For example, a man who wears his hair short or may want to wear his hair short in the future would choose FUE as the preferred harvesting method. The pinpoint scarring from FUE is less obvious to the eye than a linear scar from an ellipse.6 Meanwhile, a woman with shoulder length hair will never trim hair to 1 mm in length necessary for FUE, which makes elliptical donor harvesting the clear choice. The keys to a successful hair transplant surgery remain to be appropriate candidate selection, the skill of the physician and surgical team, and choosing the appropriate procedure for the patient. The recipient sites to place grafts in the frontal scalp are made with #19–#21 gauge needles. The grafts are placed with microvascular forceps. After the procedure, patients go home with a pressure dressing that remains on overnight. Patients are given prednisone 40 mg daily for 3 days to minimize frontal edema and 2 to 4 tablets of Tylenol #3 for pain relief. Most patients use little to no pain medication after the surgery. Patients apply petroleum jelly to the donor region twice daily for 1 week postsurgery. They shower each day by allowing the water to rinse off the scalp but to avoid scrubbing or scratching at the scalp. The perifollicular crusting that forms around the grafts resolve in 5 to 8 days. After 1 week, patients resume full sports and all physical activities. Transplanted hair takes 8 to 16 months to fully grow. Holding Solutions Another controversy in hair restoration is centered around the ideal holding solution for the time the grafts are out of the body. To date, there are no ﬁrm data how long grafts can remain in a holding solution and remain viable, but anecdotal evidence has shown that graft survival tends to decrease consistently when out of the body time is greater than 2 hours.7 There is little debate that grafts must be kept well hydrated and handled gently. Historically, normal saline has been widely used as an effective and inexpensive ﬂuid that can be used at room temperature. However, there is evidence that other aspects can and possibly should be optimized, including the temperature, osmotic balance, pH, and electrolyte balance. For instance, enzymatic activity decreases by 1.5- to 2-fold for each 10°C drop in temperature. Thus, chilling the grafts may confer a survival advantage, as demonstrated by Limmer’s study on graft survival in 1992. Likewise, Plasma-Lyte is 1 solution that more closely mimics the pH of human serum (both are 7.4 vs saline which is 5.0 and Lactated Ringers which is 6.5). HypoThermosol FRS* (Biolife Solutions, Inc., Bothell, WA) is a proprietary holding solution that was developed for optimal use at 2 to 8°C and contains the buffer HEPES. It is designed for oncotic balance, with numerous impermeant anions that will not cross the cell barriers to allow cell swelling or rupture. Liposomal adenosine triphosphate (ATP) (Energy Delivery Solutions, LLC, Jeffersonville, IN) is another interesting product that can be added to any holding solution or used as a postoperative spray to increase graft survival. It is also kept chilled but even in optimal conditions has a 2-month shelf life. In 1 study, by Jerry Cooley, survival was shown to be signiﬁcantly improved when grafts were placed in hypothermosol alone or hypothermosol with ATP as compared to normal saline.8 TABLE 1. Ellipse Versus FUE Ellipse FUE Transection rate Variable depending on training of surgical assistants <5% with trained staff Variable depending on skill of physician and device of operation of robot <5% with trained staff Sutures needed Yes No Scar Yes; linear scar visible with short hair Yes; pinpoint white scars may be visible with short hair Extensive trimming of hair in posterior scalp for donor region No Yes FUE, follicular unit extraction. S160 DERMATOLOGIC SURGERY © 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. AVRAM ET AL Recently, platelet-rich plasma (PRP) has been suggested as an alternate holding solution. To date, there are no published data to show whether PRP is able to enhance graft survival. Controversies in Medical Therapy Currently, in hair transplant clinics, all patients are counseled on medical therapy to help halt further hair loss and thus maximize the impact of any transplant long term. In the past, options were limited, with the conversation focused mainly on minoxidil and ﬁnasteride; however in the past several years, both lowlevel laser light therapy and PRP have emerged as adequate treatment options for both men and women. Low-level laser light has many dermatological applications, but with respect to hair, it was originally discovered paradoxically. At high energy, devices emitting red/near-infrared wavelengths cause hair destruction; but at lower energy, it have been found to actually stimulate hair growth. To date, many different devices exist, from laser caps to combs. A recent evidence-based review of all the trials performed show that the handful of randomized control trials provides a moderate–high level of evidence in support of these devices safety and efﬁcacy. In the authors’ experience, the results are more moderate than the other treatments already FDA approved for the treatment of pattern hair loss, although they can be a helpful adjunct. It is also important to note that these devices require that the energy reaches the scalp and thus, if the desired treatment area has moderate or better density of overlying hair, a comb may provide more efﬁcacy than a cap.9–11 Platelet-rich plasma has been utilized for years in wound healing and orthopedic conditions, but more recently it has gained traction in aesthetic medicine, especially with respect to hair loss. Several clinicians have had some success in treating alopecia of various etiologies (lichen planopilaris, alopecia areata, etc), but most of the limited data have been focused on PRP use for male- and female-pattern hair loss.12,13 Although not all is known regarding PRP’s mechanism of action, it is known that once activated, platelets are able to aggregate together and release alpha-granules containing various growth factors, such as plateletderived growth factor, transforming growth factorbeta, vascular endothelial growth factor, epidermal growth factor, ﬁbroblast growth factor, and insulinlike growth factor-1 (IGF-1). Their release increases angiogenesis and vascularization, providing resting telogen hairs the signal that they need to enter the anagen phase. This increased vascularization and mix of growth factors also fosters the proliferation of dermal papilla cells and inhibits apoptosis, helping to prolong the anagen phase. More speciﬁc to androgenetic alopecia, PRP may help to counteract certain effects of dihydrotestosterone (DHT).14 In a mouse model of androgenetic alopecia, DHT was shown to block IGF-1 contributing to hair loss and PRP is a known source of IGF-1.15 Although not all studies have shown positive results, enough literature has shown that both are capable of moderate success in treating androgenetic alopecia and have the added beneﬁt of being very well tolerated.16–24 Platelet-rich plasma is also autologous and thus provides patients a more “natural” treatment, with side effects limited to procedural discomfort and bruising. There is no standard system, quantity, or interval of treatment regarding PRP for hair loss. They currently treat patients monthly 3 times and then judge efﬁcacy after 8 to 12 months. If a patient has a response, then retreatment at follow-up may result in continued efﬁcacy if performed at a 6- to 12-month basis, although no studies have been performed to support this. With respect to hair transplantation, PRP has been discussed anecdotally in the treatment of the donor area to promote the growth of hairs transected during the procedure, use as a storage solution to keep grafts viable, and treatment of the recipient sites to promote earlier regrowth and an overall higher yield. If the recipient area is treated, it also doubles as a medical therapy for their ongoing pattern hair loss, rendering the end result potentially more dense coverage than could be achieved by transplantation alone. Only 1 study has been published to date, a single-blinded study that treated the recipient area in patients undergoing FUE with either PRP or placebo. All 20 43:11S:NOVEMBER SPECIAL ISSUE 2017 S161 © 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. HAIR TRANSPLANTATION CONTROVERSIES patients in the PRP group had >75% regrowth at 6 months post-op, compared with only 4 of 20 patients in the placebo group. The PRP group was also noted to have signiﬁcant regrowth at 8 weeks post-op, which is much earlier than expected after receiving a hair transplant.25 In the next few years, longer-term studies will help better deﬁne the medical and surgical role of PRP and hair loss. Conclusion Hair surgery has evolved signiﬁcantly since its inception in the 1960’s and 70’s. Fortunately, the newer techniques and increased knowledge has paved the way for increased graft survival and optimal cosmetic outcomes for patients. Where there is still debate and controversy, the authors’ hope it is what keeps them moving toward even better results in the future. References 1. Limmer BL. Elliptical donor stereoscopically assisted micrografting as an approach to further reﬁnement in hair transplantation. J Dermatol Surg Oncol 1994;20:789–93. 2 Rassman WR, Bernstein RM, McClellan R, Jones R, et al. Follicular unit extraction: minimally invasive surgery for hair transplantation. Dermatol Surg 2002;28:720–8. 3. Bernstein RM. Commentary on robotic follicular unit extraction in hair transplantation. Dermatol Surg 2015;41:279. 4. Avram MR, Watkins SA. Robotic follicular unit extraction in hair transplantation. Dermatol Surg 2014;40:1319–27. 5. Onda M, Igawa HH, Inoue K, Tanino R. Novel technique of follicular unit hair transplantation with a powered punching device. Dermatol Surg 2008;34:1683–8. 6. Avram MR, Rogers N, Watkins S. Side-effects from follicular unit extraction in hair transplantation. J Cutan Aesthet Surg 2014;7:177–9. 7 Limmer BL. Micrografts survival. In: Stough DB, editor. Hair Replacement. St Louis, MO: Mosby Press; 1996; pp. 147–9. 8. Cooley JE. 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Bolanca Z, plasma as a novel treatment for lichen planopillaris. Dermatol Ther 2016;29:233–5. 14. Gupta AK, Carviel J. A mechanistic model of platelet-rich plasma treatment for androgenetic alopecia. Dermatol Surg 2016;42:1335–9. 15. Zhao J, Harada N, Okajima K. Dihydrotestosterone inhibits hair growth in mice by inhibiting insulin-like growth factor-I production in dermal papillae. Growth Horm IGF Res 2011;21:260–7. 16. Takikawa M, Nakamura S, Nakamura S, Ishirara M, et al. Enhanced effect of platelet-rich plasma containing a new carrier on hair growth. Dermatol Surg 2011;37:1721–9. 17. Cervelli V, Garcovich S, Bielli A, Cervelli G, et al. The effect of autologous activated platelet rich plasma (AA-PRP) injection on pattern hair loss: clinical and histomorphometric evaluation. Biomed Res Int 2014;2014:760709. 18. Gkini MA, Kouskoukis AE, Tripsianis G, Rigopoulos D, et al. Study of platelet-rich plasma injections in the treatment of androgenetic alopecia through an one-year period. J Cutan Aesthet Surg 2014;7:213–9. 19. Singhal P, Agarwal S, Dhot PS, Sayal SK. Efﬁcacy of platelet-rich plasma in treatment of androgenic alopecia. Asian J Transfus Sci 2015; 9:159–62. 20. Betsi EE, Germain E, Kalbermatten DF, Tremp M, et al. Platelet-rich plasma injection is effective and safe for the treatment of alopecia. Eur J Plast Surg 2013;36:407–12. 21. Gentile P, Garcovich S, Bielli A, Scioli MG, et al. The effect of plateletrich plasma in hair regrowth: a randomized placebo-controlled trial. Stem Cells Transl Med 2015;4:1317–23. 22. Khatu SS, More YE, Gokhale NR, Chavhan DC, et al. Platelet-rich plasma in androgenic alopecia: myth or an effective tool. J Cutan Aesthet Surg 2014;7:107–10. 23. Puig CJ, Reese R, Peters M. Double-blind, placebo-controlled pilot study on the use of platelet-rich plasma in women with female androgenetic alopecia. Dermatol Surg 2016;42:1243–7. 24. Mapar MA, Shahriari S, Haghighizadeh MH. Efﬁcacy of platelet-rich plasma in the treatment of androgenetic (male-patterned) alopecia: a pilot randomized controlled trial. J Cosmet Laser Ther 2016;18:452–5. 25. Garg S. Outcome of intra-operative injected platelet-rich plasma therapy during follicular unit extraction hair transplant: a prospective randomised study in forty patients. J Cutan Aesthet Surg 2016;9:157–64. Address correspondence and reprint requests to: Marc R. Avram, MD, Private Practice, Dermatology, 905 Fifth Avenue, New York, NY 10021, or e-mail: email@example.com DERMATOLOGIC SURGERY © 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.