Control of Graft Depth Essential in Hair Transplantation

Many factors to create natural looking hair transplant results 

How does one great natural looking results in hair transplantation? Well there are many ways, including paying careful attention to the angle and direction that new hairs are put into the area of hair loss, controlling the density or spacing of the hairs, controlling the calibre of hairs and controlling the depth that hairs are placed.

Going deeper: Understanding Depth Control

Hair transplantation essentially involves taking follicles from the back of the scalp and moving them into areas that are thinning or bald. Small "holes" "tunnels" or incisions are created in the bald area to accommodate the new hairs. 

Creating these incisions is meticulous work. They have to be perfect. Tunnels that are too deep will cause the new hairs to sink into them creating unsightly 'pitting' (little indents around the hairs). Tunnels that are not deep enough may lead to hairs falling out or the hairs may heal as tiny mounds raise above the surface of the skin. 

 

Ensuring Proper Depth in Hair Transplant

The photo to the right shows how I ensure proper depth of a patient's grafts. The instrument on the far right is a needle attached to a blade holder. The needle must be adjusted so that it is the appropriate size.

Conclusion

A number of factors, including graft depth,  are important to ensuring natural looking results

Breast Cancer Patients on Aromatase Inhibitors: Risk of Hair loss Increased

Risk of hair loss increased two fold

Aromatase inhibitors are a group of medications used to treat breast and ovarian cancer. Common names of these drugs include Anastrozole (Arimidex), Letrozole (Femara), Exemestane (Aromasin), Vorozole (Rivizor), Formestane (Lentaron), Fadrozole (Afema). Over the past few years we've come to realize that these medications can cause hair loss in some women.

How do these medications cause hair loss?

Aromatase inhibitors cause hair loss because they reduce the levels of estrogen and increase the levels of testosterone. Both of these can contribute to hair loss.

New study quantifies risk of hair loss

A new study published in the journal Breast Cancer Research and Treatment  examined the association between aromatase inhibitor treatment and hair loss or hair thinning among female breast cancer survivors. Records were analyzed from 851 female breast cancer survivors. The results showed that 22.4 % of the breast cancer survivors reported hair loss and 31.8 % reported hair thinning. In addition,  breast cancer survivors who were within 2 years of starting aromatase inhibitor treatment at the time of survey completion were approximately two and a half times more likely to report reporting hair loss  or hair thinning  within the past 4 weeks compared to those who were never treated with these drugs. 

 This study adds to a growing body of literature showing that aromatase inhibitor use is associated with an increased risk of hair loss and hair thinning

Treatment Options: Minoxidil and Hair Transplantation.

Few studies have been done examining the optimal treatment plan. However, I have used minoxidil and hair transplantation to restore density in many patients with aromatase inhibitor induced hair loss. More studies are needed 

Reference

Gallicchio L et al. Aromatase inhibitor therapy and hair loss among breast cancer survivors. Breast Cancer Res Treat. 2013 Nov;142(2):435-43.  

 

Hair loss after brow lifts: Hair transplantation sometimes an option

Brow lifts may cause hair loss in some women

The brow lift

In this week's blog I'd like to discuss a cosmetic procedure called the "brow lift." It's not a cosmetic procedure that I do, but a cosmetic procedure that I've come to understand. I've been performing an increasing number of hair restoration procedures on for women who developed hair loss after facial plastic surgery, including brow lifts.

A browlift (also called a forehead lift) is a cosmetic surgery procedure to help minimize the sagging or drooping of the skin around the eyebrows and above the nose. According to the American Society for Aesthetic Plastic Surgery about 70,000 people have brow lifts each year.  Patients often have a brow lift to restore the appearance of a droopy eyebrow which may give the appearance of being sad, angry or tired. 

A number of surgical technique are available nowadays for performing a brow lift including endoscopic procedure and open procedures.  Some of these procedures involve incisions placed in the eyebrow, some in the forehead and some well into the hairline.

Hair loss after brow lift

Hair loss is one of the top side effects of brow lifts done by both open and endoscopic procedures. It may occur in up to 10 % of patients undergoing these procedures.  Hair loss is often temporary but may be permanent in a very small proportion. Patients with permanent hair loss from cosmetic facial plastic surgery may be candidates for hair transplant surgery.

It is important for patients undergoing cosmetic facial procedures including brow lifts to understand the potential risks of hair loss and discuss these risks with their surgeons.

Reference

Stephanie Byun et al. Complications of Browlift Techniques: A Systematic Review.  Aesthetic Surgery Journal 2013 33: 189

DANDRUFF

Scalp Dandruff:  

Scalp Dandruff: 

Nearly 50 % of the world will be affected by dandruff, the well-known flaky scalp condition. 

A number of factors contribute to dandruff including oil gland activity, a yeast known as Malassezia, the state of our immune system, stress and even some medications. 

 

What is the treatment?

Anti-dandruff shampoos are the basis of treatment - with shampoos like ketoconazole, selenium sulphide, ciclopirox and zinc pyrithione being used to treat the condition. Overall, the world spends about 2 billion dollars annually to treat this otherwise harmless condition.

Breakthrough melanoma drug causes hair loss in many

Vemurafenib causes hair loss in nearly one-half

Vemurafenib received FDA approval in 2011 for patients with metastatic or unresectable melanoma provided their melanoma cancer samples had a specific BRAF mutation. The drug has changes the way melanoma is treated with some patients now living longer on account of the drug.

Since 2011, we are now hearing abut more and more individuals who have hair loss from the drug. In fact hair loss is one of the more common side effects of this drug. Other side effects in patients treated with vemurafenib were joint pains, rash, hair loss, fatigue, photosensitivity reaction, and nausea. 

Conclusion

Hair loss is common from the new melanoma drug Vemurafenib and is likely temporary in most.  Physicians need to be aware of this side effect to counsel patients 

Reference

Kim et al. FDA Approval Summary: Vemurafenib for Treatment of Unresectable or Metastatic Melanoma with the BRAF V600E Mutation. Clin Cancer Res. 2014 Aug 5. pii: clincanres.0776.2014. 

IMAGE OF THE WEEK (Aug 3-9, 2014)

Did you check out our image of the week?

Our image of the week for this week is an up close photo of the normal process of graying hair. The "50-50 Rule of Hair Graying" says that by age 50 about 50 % of the population has 50 % of their hair gray.

Can we prevent hair loss from chemotherapy?

Hair Loss from Chemotherapy

Hair loss from chemotherapy is one of the most distressing side effects. There has been a lot of  research looking into how to prevent hair loss from chemotherapy - or what is called "chemotherapy induced alopecia." A research group for Korea recently looked at every single study that has been published so far - in order to get a better sense of what works best.

So - what works best to prevent hair loss from chemotherapy?

Scalp cooling by far. 

In order to come to this conclusion, the authors looked at nearly 700 articles, of which a total of 8 randomized controlled trials and 9 controlled clinical trials involving about 1100 participants were reviewed. Scalp cooling came out as the most effective. Other treatments like scalp compression, a combination of cooling and compression, topical minoxidil, and Panicum miliaceum didn't seem to help much (or not at all).

What is scalp cooling?

Scalp cooling (also called scalp hypothermia) is a new treatment option that is being explored. Cooling the scalp reduces the amount of chemotherapy to the scalp. The technique is used in Canada (by some hospitals) and Europe but not in the USA. It is currently undergoing study in the US and may be approved in the USA in the near future.  The two scalp cooling agents to be on the lookout for are the Penguin Cold Cap and Dignicap. 

Reference  

Shin et al. Efficacy of Interventions for Prevention of Chemotherapy-induced alopecia: A Systematic Review and Meta-Analysis. Int J Cancer. 2014 Aug 1. doi: 10.1002/ijc.29115. [Epub ahead of print]

The antifungal drug voriconazole: can it cause hair loss?

Hair loss from Voriconazole

I enjoyed reading this new study from Michigan which showed that the antifungal drug voriconazole caused hair loss in 82 % of 152 users and was rated as severe in 15 %. In most patients the hair grew back once the drug was stopped and even in some when another antifungal drug was substituted. 

This comes as a surprise given that hair loss occurred in only 2 % of users in the premarketing clinical trials. More study is needed to better define the risks but all users of voriconazole should be advised about the side effect of hair loss. 

Reference

Malani et al. Alopecia and nail changes associated with voriconazole therapy. Clin Infect Dis. 2014 Aug 1;59(3):e61-5. 

Can piggybacks cause hairgrowth?

Do "piggy-backs" cause hair growth? 

Not usually! I enjoyed this article which showed piggyback can cause hair growth if you are 9 months old & grandpa is using minoxidil (Rogaine). 

Reference

Farsani et al. Piggyback acquired hypertrichosis. Pediatr Dermatol 2014. 31(4):520

Topical Finasteride for Men

Topical Finasteride for Hair Loss

Finasteride pills (Propecia etc) are FDA approved for the treatment of male balding. The drug reduces blood DHT and stops hair loss in 90 % of men. Side effects are the main limitation.

I just read a new study about a topical formulation of finasteride for hair loss. I was interested to see that blood DHT levels were reduced by similar amounts compared to finasteride pills. Will side effects be similar? Nobody knows. It's likely that side effects will be present. The only benefit of a topical formulation would be if side effects were lower. 

Reference

A novel finasteride 0.25% topical solution for androgenetic alopecia: pharmacokinetics and effects on plasma androgen levels in healthy male volunteers. Caserini et al. Int J Clin Pharmacol Ther. 2014 Jul 30. 

Follicular "miniaturization" in Androgenetic alopecia

What is follicular "miniaturization"?

Follicular miniaturization is a key part of the diagnosis of androgenetic alopecia. In androgenetic alopecia hair follicles get thinner and thinner over time. This occurs in both male androgenetic alopecia (sometimes called male pattern balding) and female hair loss (sometimes called female pattern hair loss)

Where on the scalp does miniaturization occur?

Miniaturization doesn't just occur anywhere. It initially occurs on the top of the scalp (vertex) and temples in men and middle of the scalp in women

Can one block this miniaturization process?

Medications like finasteride and minoxidil can help slow this process of miniaturization. In many cases non miniaturized hairs can be taken from the back of the scalp and moved into the areas of hair loss. This is the basis for a hair transplant.

FUE, Strip or ARTAS Hair Transplants: At least 5 days recovery/down time please

How soon can hair transplant patients return to their "usual" activities?

I'm often asked how soon patients can return to their usual activities. The answer is 5-7 days for FUE and 2 weeks for strip. Any sooner than that is not a good idea and something I do not recommend.

It's a mistake to think that FUE procedures require a lot less downtime than strip procedures The only difference between FUE and strip is the way the hairs are removed from the back. The way they are put in the front is exactly the same!

 

Why 5 days of downtime is needed

It takes five days for a brand new hair to adapt to it's new home. If I were to take a pair of forceps and try to pull out a graft after day 1 - it would come out! The same is true for days 2-5. However after 5 days the graft is while stable and that's when normal activity is same. 

Significant increases in blood pressure, heart rate can increase one's chances of developing graft popping (and graft loss) in the days after a transplant. 5 days rest minimum is needed - no exercise, no weight lifting, sexual activity, lifting heavy objects. In strip procedures, this is extended to 2 weeks to allow the incision to heal.

Returning to work

Provided a patient feels good,  returning to light activities at work is fine in 2-3 days. Patients with smaller procedures (especially those with existing hair) find it much easier to camouflage the look of the transplant than patients with larger procedures.

Conclusion.

It's often seen and heard that hair transplantation is a short office procedure and patients can return to their usual activities in a few days. While it's true that hair transplantation is a short office procedure, returning to usual activities is not advised for at least 5-7 days. 

Follicular Units in Hair Transplantation: The Days of Plugs are Gone

Follicular units in Hair Transplantation

Close of view of 'follicular units' two weeks after a hair transplant. In a week or two, these hairs will fall out and reemerge in 2-3 months. 

What are "follicular units"?

The buzz word of modern hair restoration is the 'follicular unit'. No longer do hair transplant surgeons move "plugs" of hair into balding areas. Nowadays, we move 'follicular units.'

The photo on the right shows a number of follicular units packed into an area of hair loss. The actual area measures less than 1 cm x 1 cm. The photo was taken two weeks after the hair transplant was performed. What you can see is the groupings of these follicular units. Many of the follicular units are two haired grafts, and some are even three haired grafts. These are the natural groupings of hairs in the scalp. By moving follicular units rather than plugs, a very natural look can be obtained. 

After a hair transplant,  follicular units develop crusts and fall out. They leave behind the root deep beneath the skin - and three months later a brand new hair is produced.

PRP for Hair Loss: Another Study Points to Benefits

PRP for Hair Loss: One More Study to Add to the List

PRP for Hair Loss

Platelet rich plasma or "PRP" for hair loss refers to the injection of a patient's platelets into the scalp in attempt to stimulate hair growth. In order to perform PRP, a small amount of a patients blood is taken (similar to getting a blood test done), and the blood is processed in a PRP machine in order to isolate the platelets.

A number of recent publications support the role of PRP in the treatment of genetic hair loss. In addition, some authors  showed that pretreatment of follicular units with PRP before transplantation resulted in improved hair growth and density.

In a new study, published in the journal Biomedical Research International, researchers from Italy performed a study in 10 men. One side of the scalp was treated with platelet rich plasma and the other side was treated with placebo (saline). Results were compared at 14 weeks, 6 months and 1 year. 

What are the results?

The results of the study showed a significant increase in hair count for the treatment area after just 3 months. There was an increase total hair density of 27.7 hairs per  square cm compared to baseline.  In addition, terminal hair density improved significantly by 27.0 ± 15.3 (number of hairs/cm2) in the treatment area, while decreasing by 2.1 ± 12.4   in the control area of the scalp.

Conclusion

We are no longer in the era where we "wonder" if PRP works to help those with hair loss. Rather we have moved into the era where we know if helps and now need to determine what is the best way to perform PRP.

What is the best machines to use to prepare PRP (what machine should physicians buy)?

What is the optimal amount of PRP to inject (is too much going to be bad)? 

What is the optimal frequency to repeat PRP injections for those with hair loss (1 month 4 months, 6 months)?

However, this Italian study adds to a growing list of studies showing that PRP is a bonafide treatment for hair loss.  

References

Cervelli 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: 7  

 

Other References:

1. Takikawa M, Nakamura S, Nakamura S, et al. Enhanced effect of platelet-rich plasma containing a new carrier on hair growth. Dermatologic Surgery. 2011;37(12):1721–1729. [PubMed]

2. Li ZJ, Choi H-I, Choi D-K, et al. Autologous platelet-rich plasma: a potential therapeutic tool for promoting hair growth. Dermatologic Surgery. 2012;38(7, part 11):1040–1046. [PubMed]

3. Uebel CO, da Silva JB, Cantarelli D, Martins P. The role of platelet plasma growth factors in male pattern baldness surgery. Plastic and Reconstructive Surgery. 2006;118(6):1458–1466. [PubMed]

4. Trink A, Sorbellini E, Bezzola P, et al. A randomized, double-blind, placebo- and active-controlled, half-head study to evaluate the effects of platelet-rich plasma on alopecia areata. British Journal of Dermatology. 2013;169(3):690–694. [PubMed]

Minoxidil - How long should I leave it on?

Minoxidil - what's the minimum time to leave it on and still work?

Minoxidil has been in the market for about 25 years, receiving FDA approval in 1988. Many people recognize one of the popular brand names - Rogaine. Minoxidil is approved male pattern balding (androgenetic alopecia) as well as female pattern hair loss. It can also be used to treat several other conditions. In women, minoxidil can be used before and after a hair transplant to reduce the chances of post operative shedding. Some patients also use minoxidil after a transplant to speed up the rate of growth of the grafts.

How long should I leave the minoxidil on the scalp?

A common question I'm asked is how long to leave the minoxidil on the scalp. Ideally it is left on for 8 hours but the 'minimum' time I advise is 4-6 hours. After 4 hours, 75 % of the minoxidil is absorbed.

This advice comes from a 1990 study. In that study, twenty-two healthy male volunteers completed a four-way, multiple-dose, randomized crossover study to determine the relationship between contact time of applied drug on the scalp and minoxidil absorption from a 2% topical solution.  The researchers examined how much minoxidil is absorbed at 1 hr, 4 hr compared to 11.5 hours. Relative to the amount absorbed after a contact time of 11.5 h, absorption was approximately 50% complete by 1 h and greater than 75% complete by 4 h.

Conclusion:

Although minoxidil should ideally be left on 8 hours, tremendous benefit can still be achieved with 4 hour use. Understanding the absorption of minoxidil is important to help improve the ability of patients to 'stick with' the treatment. 

Reference

Ferry JJ et al. Relationship between contact time of applied dose and percutaneous absorption of minoxidil from a topical solution. J Pharm Sci. 1990 Jun;79(6):483-6.

Follicular Unit Extraction (FUE) for Grey/White Hair

FUE for Grey/White Hair

Follicular unit extraction (FUE) is a method of removing hair from the back of the scalp ('donor area') one by one. It is often considered in men who wish to wear their hair short because it does not create a linear scar.  By linear scar, I simply mean a scar that appears as a thin thin.

FUE is more challenging in patients with certain hair characteristics, including those with very curly hair and those with grey/white hair. However, with careful planning, their are ways to overcome these challenges.

1. FUE for Curly Hair (Black men and women).

A previous blog I wrote last year discussed ways of successfully performing FUE for black men and women.

2. FUE for Grey/White Hair

FUE is more challenging in those with grey white hair because it is more challenging to see the angle of the hairs beneath the scalp.  Theoretically, if the angle can not be properly seen, the rate of injury or transection goes up considerably.  We encourage our FUE patients with grey/white hair to dye their hair 4 days before the procedure and to wash the scalp daily in the days leading up to the procedure. This allows us to visualize the hairs more effectively and reduce transection rates during FUE extraction.

Comment:

Contrary to popular views, FUE is not for everyone.  However, with careful planning and design of the procedure, a large number of patients who might otherwise be considered poor candidates for FUE can be offered the procedure.

Minoxidil for Eyebrows: Worth Considering Before Eyebrow Transplantation

Thinning Eyebrows: Hair Transplant vs Minoxidil

Thin eyebrows are common and we're seeing more and more patients (both men and women) who are looking to enhance their eyebrows. For some of my patients, it's clear that eyebrow transplants are the only method to restore the density they are looking for.  For other patients, a trial of topical minoxidil is worthwhile before considering a hair transplant.

Minoxidil for eyebrows: New study suggests benefit

Topical minoxidil can be applied to enhance eyebrows. Until recently, there was no good study comparing minoxidil lotion with placebo for eyebrow enhancement. Researchers from Japan determined the efficacy and safety of minoxidil 2% lotion for eyebrow enhancement compared with placebo. 40 patients were randomized for minoxidil on the eyebrow on one side of the face and placebo on the other. Efficacy was evaluated by photographs, measurement of eyebrow diameter, eyebrow count and the satisfaction of study participants. Side-effects were also evaluated.

What were the results of the study?

Thirty-nine patients (97.5%) completed the study. After 16 weeks, the minoxidil group achieved significantly better results in all measured outcomes compared to the placebo group. Side-effects were minor and did not preclude patients from continuing the study. The conclusion of the study was that minoxidil 2% lotion is a safe and effective treatment for individuals with age related or genetically thin eyebrows.

Reference of Interest

Lee S et al. Minoxidil 2% lotion for eyebrow enhancement: a randomized, double-blind, placebo-controlled, spilt-face comparative study. J Dermatol. 2014 Feb;41(2):149-52. 

 

Scalp Dermoscopy

Scalp Dermoscopy.

A "dermatoscope" is a hand held device that uses magnification, and a transiluminating source (sometimes with polarized light) to better evaluate hair loss patterns. I have several types of dermatoscopes. Most images here in my blog have been shot with a device known as Dermlite Pro HRII or Dermlite DL. A dermatoscope is essential to the proper evaluation of hair loss.

Can men use dutasteride and finasteride together?

Finasteride is formally FDA approved for the treatment of male balding. While not formally FDA approved, dutasteride can be used off label in the treatment of male balding or 'androgenetic alopecia'. Both drugs can be used alone or with other therapies such as hair transplantation, minoxidil and platelet rich plasma. 

Finasateride is an inhibitor of the enzyme 5 alpha reductase type 2  and dutaseride is an inhibitor of both 5 alpha reductease type 1 and type 2. Dutasteride is more potent and leads to greater reductions of dihydrotestosterone (DHT). Side effects are also greater.

Patients who have a partial response to finasteride often wonder if they should switch to dutaseteride or add dutasteride. Adding a very small dose of once weekly dutasteride can often be a good option. An Australian study in 2013 reported a 47-year-old man who was initially treated with finasteride for male pattern balding. Despite continuous treatment, after year 4 his hair density was not as good as previous years, and low-dose dutasteride at 0.5 mg once per week was added to the finasteride therapy. Interestingly, this resulted in a dramatic increase in his hair density, demonstrating that combined therapy with finasteride and dutasteride can improve hair density in patients already taking finasteride.

Comment

This study shows how careful planning of safe medical treatments can lead to improvements in patient's outcomes.

Reference

Boyapati A and Sinclair R. Combination therapy with finasteride and low-dose dutasteride in the treatment of androgenetic alopecia. Australas J Dermatol. 2013 Feb;54(1):49-51.  

 

Topical ketoconazole shampoos: Are they helpful for hair loss?

Ketocaonzole shampoos promotes hair growth

Ketocaonzole is a an antifungal agent and effective for the treatment of seborrheic dermatitis and "dandruff". But research over the past many years has suggested that they help hair loss as well. I often recommend that individuals with genetic hair loss consider use of anti-inflammatory shampoos.

What were the results of ketoconazole studies for hair loss?

A 21 month study  compared the use of topical minoxidil to ketoconazole 2 % shampoo. Study participants received the 2 % shampoo or an unmedicated shampoo with or without minoxidil 2 %. Interestingly, hair density and follicle size improvements were similar with both ketoconazole and minoxidil regimens.

How do ketoconazole shampoos help hair loss?

The mechanism by which topical ketoconazole improves hair density and hair growth is unclear, but may be due to is anti-inflammatory effects against T cells and the yeast of the scalp which create inflammation (Malassezia yeast). Ketoconaozle also inhibits steroidogenesis and decreases DHT levels.

References

Inui.  J dermatol Sci 2007; 45: 66-8.

Pierar Franchimont Dermatology 1998; 196: 474-7