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Hair Transplant Test Sessions for Scarring Alopecia

Common Errors in Performing 'Test Sesssions'  

Hair transplants can be an option for patients with scarring alopecia but only if certain criteria are met. First and foremost, the disease should ideally be completely 'inactive' for at least 2 years and the patient should be off all types of immunosuppressive medications. Unless these minimal criteria are met, we can't be sure the scarring alopecia is truly quiet (inactive).

test-sessions

Sometimes a hair transplant “test session” is performed 8-12 month prior to proceeding to the ultimate full hair transplant session. The purpose of the “test session” is to better estimate the chances of success of a larger transplant session. Patients with a successful test session are given the green light to proceed to a full session. Patients with a poor outcome on the tests session may be advised not to proceed with hair restoration in the near future. 

I think there is a lot of misunderstanding about how to perform a test grafting session for a patient with scarring alopecia. Below I outline some common errors. But first, let me begin with an analogy. 

 

Hair Transplant Test Sessions: An Analogy

I often use the following analogy when explaining the concepts I believe are important in  a hair transplant tes session. As an analogy. imagine yourself offered an exciting job position. 9 months of the year you’ll be travelling to the world's most exotic destinations. The only catch is that 12 weeks of the year, you'll need to be in the arctic circle during the middle of winter. Each day, you’ll need to walk 20 miles through ice and snow collecting various samples. You’ll sleep in a tent each night and you need to carry all your belongings with you. 

You are really not sure if you’ll be able to withstand the cold and all your friends think you’ll crazy for thinking about accepting the position as they think you are far to soft of a person to withstand the cold and extremes of the artic circles. To test whether you can really survive an article winter,  you decide to make a “test visit” for 1 month to see if you’ll really like living there or not. You figure if you can survive 4 weeks, 12 weeks should not be so bad. 

As you are deciding when to go, a friend advises you to go in the summer since she’s heard it’s lovely in the summer. Another friend advises you to go in the winter but stay at some luxury accommodations he’s heard good things about.   

In my opinion, neither pieces of advise from these friends is really ideal for a ‘test visit.’  To challenge yourself to see if you are really going to withstand the arctic winter, you need to visit in the winter - and you need to stay in lodging that best represents how you’ll live if you do decide to move. That lodging is, of course, a tent. It’s reasonable to bring two blankets with you and a few more warm belongings that most people who live in the area normally use – because let’s face it – the whole experience is completely new to you. 

The same is true with a transplant test session. The whole experience of moving from a warm, richly vascularized area into a scarred, poorly vascularized area is a big challenge for a little hair follicle. During a 'test session, I believe one needs to challenge these little hairs and see if they really can make it. One needs to make the scalp suitable to growing but not too perfect and luxurious that it falsely misrepresents the challenges that will ultimately be present if a real transplant is performed. Newly transplanted hairs are not really used to growing in scar tissue and not used to growing in between the little bits of inflammation that are often there – so it’s reasonable to help them out a bit. But my opinion is that a test session should truly be a test session. The hairs need to be tested !

 

COMMON ERRORS IN "TEST SESSIONS"

1.     Excessive topical corticosteroids and immunosuppressives are used

A test session is really all about testing whether hairs can withstand the challenges of growing in less than ideal conditions. The new grafts need to grow in scarred scalp tissue that may lack ideal blood supply. The skin itself may be too thick or too thin.

As part of the test session, I believe on should use minimal corticosteroids (and minimal other immunosuppressives if at all possible). It's still okay to use them but just not excessively.  I typically recommend steroids a few times per week before the test transplant with steroids stopped one month before. Steroids are started again 1 month after the test session but only twice weekly for two months and then once weekly thereafter.  A mid potency topical steroid should be sufficient.

One needs to challenge these little hairs and see if they really can make it. One needs to make the scalp suitable to growing but not too perfect and luxurious that it falsely misrepresents the challenges that will ultimately be present if a real transplant is performed. The analogy is similar to the arctic circle analogy I used above. 

 

2.     The grafts are spaced too far apart

Ideally, 100-200 grafts should be put in an area at a density of 25-30 follicular units per cm2 and this area carefully followed over time. The problem with placing grafts at a lesser density is that it does not adequately ‘stress’ the hair follicles during the test session. When it comes to growing in scar tissue, it’s easier for hairs to grow when they are far apart rather than close together. My view is that during a ‘test session’we need to understand how the hair follicles survive under realistic situations. If the patient ultimately proceed to a full hair transplant session, follicle are going to be transplanted at a density of 20-25 follicular units per square cm AT MINIMUM and so a test session should slightly exceed this. We need to test the follicles!

 

3.     Too many grafts are put in

I don’t recommend that test sessions be done with more than 200 grafts and 150 is often ideal. The problem with doing more than 200 is that it become difficult to count the grafts. 

I have seen patients who come to see me after have 500-800 grafts ‘peppered’ into the front of the scalp or ‘peppered’ into the crown. Instead of putting 100-150 follicles in to an area the size of a golf ball, 500-800 grafts get put into an area the size of a large melon or small dinner plate. It is easy to count 100-200 grafts (1, 2, 3, 4…) but more difficult to count 500. When it comes to hari transplant test session, I believe we need accurate survival numbers. Knowing that 90% survived is very different than knowing 54 % survived. Knowing that the survival 'seemed ok' is very different than knowing that the survival was 'excellent.'

 

4.     The grafts are put into an area already containing hair follicles

In my opinion, a test session should be performed in an area with as few hairs as possible, ideally with no hair. Sometimes this is not possible, but if it is –this should be followed. This makes it easier to document “before and after”photographs, count hairs and document clearly the survival of grafts. 

The problem with putting in 500-1000 grafts in area area that already has hair, is that it becomes impossible to really get a sense of the proportion of grafts surviving at a time 9-12 months post op. I saw a patient recently who had 500 grafts placed into his crown. The test session was performed in an area that was thinning but not bald. It was impossible to really get a sense of how many grafts survived, despite the fact that the surgeon estimated survival waspretty good. Photos suggested there were no changes to the density and the patient felt it had worsened! Objective measurements are what is needed in these test session.  

 

5.     The grafts are put in an area that is not representative of the actual scalp to be transplanted

Hair follicles need to be placed in an area that is representative of the average quality of the skin of the scalp, and possibly even in an area that represents slightly poorer than average quality. If much of the scalp contain thicker areas of scar tissue, this is not unreasonable to perform the test session in there. If most of the scalp is thick pale, poorly vascularized tissue and only a small portion of the scalp is pink normal appearing skin, it is misrepresentative to perform the test tession in the pink, normal appearing area.  


Returning to the analogy above, it is unreasonable (in my opinion) for a person undergoing a test visit to the article circle to stay in a luxury accommodation during the visit when the whole purpose of the visit is to see if one can really withstand the extremes of living in the article circle. In the same way, it is unreasonable to make the test session a wonderful opportunity for hair growth.

 

A test session should represent a true... test!


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Hair Transplants from Another Person?

Can I get a hair transplant from someone else?

In theory, that answer is yes. Theoretically speaking, it would be possible to take hair from another person (the donor) and transplant it to another person (the recipient) and have the receipt use immunosuppressive medications for life in order to keep their hair growing and prevent rejection. However, practically speaking that answer is no. In the current day it is not possible.

 

Why no?

The incorrect assumption that people make is that immunosuppressive medications are safe. Immunosuppressive medications have very serious side effects and don’t prevent rejection in everyone. Inmunnosuppressive pills affect blood pressure, liver function, cholesterol, mood, blood sugars, bone health, weight, kidney function. They can increase the risk of developing various types of infections and increase the risk of cancer. Organ transplant recipients have shorter life expectancies and a higher risk of dying of both cancer and non–cancer-related causes  These drugs have potentially serious side effects when used to prevent rejection. For that reason, it is not possible.

Interestingly, there are a few rare situations where it would be possible to receive donor hair from another person.  The main one would be a hair transplant in identical twins.  Identical twins have the same genetic material and a hair transplant could be performed without the need for anti-rejection drugs.  

 

Can I at least try?

Having encountered this question from patients countless numbers of times, I have come to realize that despite the above information, the question often follows -  "can't I at least try?" The short answer is that no, it is not possible to perform a hair transplant using donor hair from another person. In most jurisdictions, it would even be considered malpractice for a physician to even consider performing this procedure in such a situation. However one looks at it, it is not possible and not permitted. 

Someday, it will be possible to produce hair follicles form a variety of sources. Exciting research is currently being conducted that makes things that would otherwise seem impossible - possible.

 

Reference

Source: Rosati P and Bergamo A. Allogenic hair transplant in a bone marrow transplant recipient. Dermatol Surg 1999; 25: 664-5.

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Hair Transplants in Young Men

Are hair transplants an option under 25?

Hair transplantation is rarely a good option in men under 25 and it's generally never an option for men in the early 20s (i.e. before age 23). I completely understand that hair transplants are performed around the world in young men age 18-22. However, I don't think it's a good idea.

 

Why hair transplants in young men is not advisable

In an effort to look better and do something positive, many men rush into hair transplants. Not a day goes by that I don't see it or hear it.  There are a number of things that all young men should keep in mind.

 

1. Hair loss does not stop - it continues forever

Too many young men forget that hair loss will continue forever. If a patient is developing genetic hair loss at a young age, one thing is for sure: they will continue to slowly bald unless medication treatment is considered.  Having a hair transplant does not stop the balding process - it only delays the appearance.

 

2. Males who start balding in the early 20s are likely to develop advanced balding patterns in their 30s and 40s. 

It is critically important to understand that once genetic hair loss starts, it will continue forever. If balding starts at a young age, there is a very high chance that male will develop more significant hair loss in the 30s, 40s or 50s.  

 

3. Males who have hair transplants in the early 20s must be prepared for more surgeries throughout their lifetime

If a hair transplant is performed in the frontal hairline at too young of an age, the hairs that are moved into the frontal hairline may last a long time. However, the hairs 'behind' this frontal area could potentially disappear as normal balding continues along its course. At hair transplant performed at too young of an age often leads to placement of place hairs in an area which could look unnatural in the future. A good example would be the placement of too low of a hairline or a hairline with not enough curve to it.  In order for the patient to continue to look good and not have a 'gap' develop between the transplanted hairs and the continually receding hairline, the patient must return to the surgery centre from time to time for more transplants. In other words, if needs to be prepared for a lifetime of hair transplants. Therefore, a hair transplant is not a one time thing.

 

4. It's nearly impossible to predict prior to the mid 20s how many donor hairs a patient actually has. 

If humans had an infinite number of hairs in the “donor” area to move through hair transplants, I would be more likely to advise that more young men move forward and have hair transplants. However, hair in the donor area at the back of the scalp is present in limited supply. A young male with balding may have anywhere from 0 hairs to move (if they have diffuse unpatterned alopecia or DUPA) to up to 8000 folllicular units to move in his lifetime. It may not be clear until the mid to late 20s whether the number is closer to zero or closer to 8000.

Before the mid 20s, one needs to keep in mind that it is just a 'guess' as to how best to use hair transplant grafts from the back of the scalp.  As one ages, it becomes much clearer as to where it is best to place these grafts.  

 

Conclusion

It's rarely a good idea for a young man to have a hair transplant before the mid 20s. There are exceptions whereby a hair transplant in a 23 or 24 year old can be life altering - but these are rare exceptions. In most cases, I recommend these young patients strongly consider non surgical treatments to try to stop their hair loss before considering hair transplantation.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Poor growth after hair transplants: Why?

Poor growth after hair transplants:  

By 8 months, a hair transplant patient should have a fairly good idea of the growth. While it's true that it can take longer (.... even up to 18 months), the vast vast majority of patients experience some nice growth by 8 months. There is no harm in waiting a bit longer - but improvement is (statistically speaking) quickly unlikely.  


Fortunately, poor hair growth following hair transplantation is not something that happens all that often. But when it occurs the surgeon will need to explore many, many possibilities, including patient factors, physician factors and scalp factors. All in all, anyone with poor growth needs to sit down with their physician to review things in detail. 




PATIENT FACTORS


There are a few patient factors to consider - and many are centred around post op care of the grafts. The other patient factor that is important is smoking. Occasionally, smokers have poor growth for reasons that are not completely understood. Other factors one might think about under patient factors are medications that impair hair growth or cause excessive bleeding. There are a few other factors as well that a surgeon will review with a patient with poor growth. 




PHYSICIAN FACTORS


Physician factors also include the physician and his or her hair transplant team. These factors  include overly tight packing of the grafts (too tight, too packed can lead to poor growth) improper depth of grafts, rough handling of grafts by technicians, harvesting of grafts, temperature of grafts and poor hydration of the grafts. All these things are important. Sometimes the density is too high to begin with in certain areas. But these are the things to think about in the "Physician Factors"
 


SCALP FACTORS


This is also an important categories. Some scalps (because of excessive sun damage or other factors) may take up grafts less efficiently and this leads to poor growth. Some scalps bleed more than others are this can rarely impact growth due to post operative "popping" of grafts. Infection post surgery can impair growth as well. And finally some patients have scalp diseases that are either present before the surgery (but could not be detected) or some patients develop new scalp diseases after the surgery that impairs the growth of the grafts. This is rare. For example some individuals rarely develop alopecia areata or rarely develop scarring hair loss problems after their hair transplant. These scalp issues can impair growth partially or completely. A scalp biopsy is sometimes needed to diagnose these problems.

 

CONCLUSION
 

As you can see there are many, many possible reasons and only with a careful evaluation and a bit of "detective work" can a few possibilities be uncovered. That said, sometimes hair transplants don't generate the results that were expected and the next time they do. Any surgeon will tell you in a busy practice, there are occasionally patient's the have less than expected growth. Hair transplant is a fascinating science - but not an exact science.  Far from it. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Hair Transplants for Folliculitis Decalvans: Is it even possible?

FOLLICULITIS DECALVANS

HAIR TRANSPLANT CANDIDACY CRITERIA

 

fd.jpg

The criteria we use in our clinic for evaluating folliculitis decalvans candidacy are among the most strict of all the scarring alopecia criteria. Hair transplants for folliculitis declavans can be very challenging. Chances of success are low although successes to occur. In order to be a candidate for hair transplant surgery,  ALL FIVE of the following criteria must be met in a patient with folliculitis decalvans:

 

1.  The PATIENT should be off all hair-related medications.

Ideally the patient should be off all topical, oral and injection medications to truly know that the disease is "burned out (burnt out)". However, in some RARE cases, it may be possible to perform a transplant in someone using medications AND who meets criteria 2, 3 and 4 below.  This should only be done on a case by case basis and in rare circumstances. It is a 'last resort' in a well-informed patient. 

 

2. The PATIENT must not report symptoms related to the FD in the past 24 months. 

The patient must have no significant itching, burning or pain and no bleeding. One must always keep in mind that the absence of symptoms does not prove the disease is quiet.  Even the periodic development of itching or burning from time to time could indicate the disease has triggers that cause a flare and that the patient is not a candidate for surgery. The patient who dabs a bit of clobetasol now and then on the scalp to control a bit of itching may also have disease that is not completely quiet.  The patient with itching every now and then is also a worry. 

 

3. The PHYSICIAN must make note of no clinical evidence of active disease in the past 24 months. 

There must be no scalp clinical evidence of active FD such as perifollicular erythema, pustules, crusting, perifollicular scale (follicular hyperkeratosis). This assessment is best done with a patient who has not washed his or her hair for 48 hours.

The most important clinical features in our opinion are SCALP CRUSTING and REDNESS AROUND THE HAIRS. Some scalp redness may be persistent in patients with scarring alopecia even when the disease is quiet. Therefore scalp redness alone does not necessarily equate to a concerning finding. Perifollicular redness (redness around the hairs) however is more concerning for disease activity.  In addition, the pull test must be completely negative for anagen hairs and less than 4 for telogen hairs.  A positive pull test for anagen hairs indicates an active scarring alopecia regardless of any other criteria.

 

4. Both the PATIENT and PHYSICIAN must demonstrate no evidence of ongoing hair loss over the past 24 months.  

There must be no further hair loss over a period of 24 months of monitoring off the previous hair loss treatment medications. This general includes the patient's perceptions and physician's perception that there has been no further loss, physician's measurements showing no changes in the areas of hair loss, as well as serial photographs every 6-12 months showing no changes. 

 

5. The patient must have sufficient donor hair for the transplant. 

Not all patients with FD have sufficient donor hair even if their disease has become quiet.   

In situations where there is concern that the FD may be active or concern that the surgery may not be a success, strong consideration should be given to performing a 'test session' of 50-100 grafts and observing their survival over a period of 6-9 months. Less than 40 % uptake would intake a contraindication, although ideally one would hope for survival of more than 70% of the grafts.

 

For Further Reading

 

Lichen Planopilaris Transplant Candidacy

Frontal Fibrosing Alopecia Transplant Candidacy

Trichotillomania Candidacy: Can a patient with trichotillomania have a hair transplant?  

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Are hair transplants possible for individuals with scarring alopecia?

Are hair transplants a good option for scarring alopecia?

LPP-HT

The answer to that questions is sometimes "yes" and sometimes "no". For many individuals who step into the office, the answer is frequently "no". A hair transplant is not a good option for them - at least right now. Not because we can't perform hair transplants in individuals with scarring alopecia but rather because the person sitting in front of me has a scarring alopecia that is currently active. They have ongoing hair loss and they report they have less hair than one year ago. Some have persistent itching, burning or tenderness in the scalp. These individuals are not candidates for a hair transplant any time soon.



A Balanced View of Hair Transplantation

It might sound surprisingly to have such a negative view of hair restoration for scarring alopecia. I would say that my view is balanced. The positive side of this topic is that a hair transplant can be a good option once the disease becomes quiet ... and stays quiet for a few years (ideally off medication). On previous blogs,  I have shared my personal views on the criteria we use when considering whether an individual is a good candidate for a hair transplant. These are mainly centered around lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) as these have been studied most extensively in our center.

CRITERIA FOR TRANSPLANTATION OF LPP

CRITERIA FOR TRANSPLANTATION OF FFA

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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7 Hair Transplant Myths

7 Common Myths in Hair Transplantation

Hair transplantation is among the mostly consistently successful and  life-changing of all the hair loss therapies. Hair transplants nowadays can look extremely natural (when performed by skilled teams). However, there are a number of myths that are infrequently talked about when it comes to hair transplantation.  These can sometimes be overlooked.

 

1.     Transplanted hair lasts forever

It’s a common myth that transplanted hair moved during a hair transplant last forever. Fortunately, most hairs that are transplanted do generally remain in their new location forever. However, anyone is has followed a hair transplant patient for 10, 20 or 30 years will tell you that the same number of hairs that were put in are not always remaining over time. Most will stay - but not all

There are many reasons why hairs transplanted hairs don’t always last forever. For one, donor hair is not always completely resistant to balding in all men. In fact, it’s a spectrum, from some men who have very little to no balding in their "donor area" (at the back of the scalp) to men who have considerable thinning in the donor area over time (ie. men with DUPA are the extreme). In addition, the medical community has not rigorously studied long term the immunological and physiological changes that happen to transplanted hairs over extended periods of time.

Nevertheless, there is no arguing that transplanted hairs last forever. It holds true for a high proportion of men and women but not all. We hope they last forever are and they seem to be in many men. However, a proportion of transplanted hairs slowly disappear over decades in some men.

 

2.     Only one hair transplant surgery session is needed

From the time male balding and female thinning announces its presence in any patient, it always progresses. While it is true that androgenetic alopecia can stop or slow for periods of months to a year or two, androgenetic alopecia by definition never stops. Anyone who gets a hair transplant must assume that existing hair in an area will slowly thin over time. If a patient is under 30 years of age, he (or she) must assume that another hair transplant will likely be needed if he wishes to maintain his current look into his 50s and 60s.

 

3.     A hair transplant procedure is always a great success

Hair transplants are generally quite successful. That's why they are popular! With the right patient, and a skilled team, the chances of success are high. Unfortunately, hair transplant don’t always work out as successfully as one might hope. There is not an experienced hair transplant surgeon in the world who can state that he or she has never had a patient who did not grow as much hair as they hoped. The reasons why this occurs is quite varied - but ranges from "patient factors" (post op care, smoking, unrecognized scalp diseases), to "surgeon-related" factors (surgeon skill, skill of the technicians handling the grafts). Sometimes one never knows the exact reason why things don’t turn out. In the hair transplant field, this is called the ‘X factor.’

 

4.     A hair transplant is a one-day event

A hair transplant procedure itself is a one day event, but the actual procedure when one considers the time from the surgery to the time where the patient feels back to normal ranges from a few days to a few months.  The actual recovery time varies from patient to patient and varies based on the size of the surgery.

In general, the post op recovery period is longer for FUT procedures than FUE and longer for patients that require more grafts. Patients who don’t require shaving for FUE procedures and have limited baldness, may find that 2-3 days is sufficient to feel back to their usual self.  However, a patient whose scalp is shaved completely for a large 3000-4000 FUE procedures may find that it takes just a few days to “feel good” but takes 3-4 weeks before he feel confident to go to work. Depending on his occupation, he may or may not feel comfortable at work for an extended period. A patient who sees clients on a daily basis at work may not feel completely comfortable seeing his clients even after 2 weeks post op from a 4000 graft FUE.  This needs to be taken into account. A hair transplant is not always a ‘one day thing.’

 

5.     A hair transplant is always an option for treating hair loss

It’s a myth that a hair transplant is always an option for an individual with hair loss. Some patients may be too young, some have medical issues that preclude surgery, and some have a type of hair loss that also will not be successful if a hair transplant were performed. Hair transplants aren't for everyone.

 

6.     There are no complications to a hair transplant

Hair transplants are quite safe. But it’s a bit of a stretch to say that they are without complication. Patients may have have redness, swelling and crusting post operatively. In general, the recovery in FUE procedures is much easier than FUT procedures.  But there are rare complications in hair transplant surgery that include long lasting nerve pain (more in FUT than FUE procedures) and persistent scalp redness. Unless a physician is carefully monitoring the procedure, a patient can even get sick. The hair transplant community tends to shy away from calling hair transplant procedures a 'surgery' in order to make the procedure more patient friendly - but make no mistake a hair transplant is a surgery. 

 

7.     You will regain the hair density of your youth

A hair transplant is a surgical procedure which involved moving anywhere from 10 to 10,000 hairs into an area of balding. If an area of hair loss is small, it may be possible to build some very nice density in the area – but the density is generally less than it once was. For example, in a patient who is very bald, a density of 35-40 follicular units per square centimeter will typically be created.  This area likely had a density of 90 or more follicular units per square centimeter at one time years earlier. Therefore, it is generally the norm for a hair transplant to create results that are less dense than the original density. A skilled surgeon can often help make 35-40 follicular units look like the original density. However, photos and videos of patients with amazingly thick and dense hair following their procedure may not always be accurate.  


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Hair transplants for Scarring Alopecia

How successful are hair transplants in scarring alopecias?

worldwide.jpg


This is an in important question and one that needs good data. I serve as the chair of a committee of the International Society of Hair Restoration Surgery. On Friday we sent out a survey to hair transplant surgeons around the world with the hopes of gathering more information on the successes and failures surgeons have had when transplanting scarring alopecias.

There is no doubt that hair transplantation works wonderfully in some patients with scarring alopecia and does not work well in others. One must always have quiet (inactive) disease for at least 1-2 years before a transplant is attempted.

 

What are the criteria for transplanting scarring alopecia?

In general, a scarring alopecia must be quiet for 1-2 years before a transplant can be even considered. Several years ago I put forth criteria for determining if an individual with lichen planopilaris is a hair transplant candidate:

 

Criteria for Hair Transplantation Candidacy in LPP

1.  The PATIENT should be off medications.

Ideally the patient should be off all topical, oral and injection medications to truly know that the disease is burnt out and ‘inactive’. However, in RARE cases, it may be possible to perform a transplant in someone using medications AND who meets criteria 2, 3 and 4 below.  This should only be done on a case by case basis and in rare circumstances as the risk for disease reactivation is high.  A patient using medications to suppress disease activity is at high risk for reactivation following hair transplant surgery. It is a last resort in a well-informed patient.

2. The PATIENT must not report symptoms related to the LPP in the past 12 months, (and ideally 24 months).

The patient must have no significant itching, burning or pain. One must always keep in mind that the absence of symptoms does not prove the disease is quiet but the presence of symptoms certainly raises suspicion the disease could be active.  Even the periodic development of itching or burning from time to time could indicate the disease has triggers that cause a flare and that the patient is not a candidate for surgery. The patient who dabs a bit of clobetasol now and then on the scalp to control a bit of itching may also have disease that is not completely quiet. 

3. The PHYSICIAN must make note of no clinical evidence of active LPP in the past 12 months, (and ideally 24 months).

There must be no scalp clinical evidence of active LPP such as perifollicular erythema, perifollicular scale (follicular hyperkeratosis). In addition, the pull test must be negative. 

4. Both the PATIENT and PHYSICIAN must show no evidence of ongoing hair loss over the past 12 months (and ideally 24 months). 

There must be no further hair loss over a period of 24 months of monitoring off the previous hair loss treatment medications. This general includes the patient and physician's perception that there has been no further loss as well as serial photographs every 6-12 months showing no changes.  As discussed above, the 12 month waiting time is the standard of care as an accepted definition for hair transplant candidacy.

5. The patient must have sufficient donor hair for the transplant.

Not all patients with LPP maintain sufficient donor hair even if the disease has become quiet. 

 

Disease Reactivation Following Surgery

My research has focused on the chances of reactivation of LPP after surgery. It is important to be aware that ANY patient with LPP is at risk for reactivation or a 'flare' of their LPP after surgery.  The risk, I estimate, is as follows:

 

LPP Reactivation Risk (Donovan, J, unpublished data)

i)               A patient with active LPP before their transplant is nearly guaranteed to have a flare of his or her LPP if a hair transplant is done. (estimate 90-100 % chance of flare within 2 years post transplant)

ii)             A patient with partially active LPP before their transplant is very likely to have a flare if a hair transplant is done. (estimate 70-90 % chance of flare within 2 years post transplant)

iii)            A patient with medication induced inactive LPP before their transplant has a moderate chance of a flare if a hair transplant is done (estimate 50-70 % chance of flare within 2 years post transplant)

iv)            A patient with inactive LPP off all medications for 1 year before their transplant has a low chance of a flare if a hair transplant is done (estimate 10-25 % chance of flare within 2 years post transplant)

v)             A patient with inactive LPP off all medications for 2 years before their transplant has a low but definite chance of a flare if a hair transplant is done (estimate less than 10% chance of flare within 2 years post transplant)

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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