Hair Transplantation for Donor Area Scars: Options for Further Camouflage

Options for Camouflage Hair Transplant Donor Area Scars:  

 

Consider the following scenario.

A patient has had a previous hair transplant by the strip procedure (follicular unit strip surgery, FUSS). He enjoys wearing his hair short. At times he notices that when he wears his hair quite short the scar is a bit more visible. He wants to reduce that visibility.

 

What are the options to camouflage the scar even further if he wants to wear hair short?

1. FUE into the scar

In some patients, we can remove 25-200 grafts from surrounding areas and place them into the scar. This can help camouflage the scar. Because so few grafts are needed, we can perform this procedure with minimal downtime for the patient. 

2. Scalp Micropigmentation  (SMP)

Scalp micropigmentation is proving to be a very useful technique to tattoo scars.  SMP allows small circular dots to be placed into the scar in a manner than resembles hair follicles cut in cross section. The dots are the same color as the patient's hair and this creates a nature look.

Proper Selection is Essential for Hair Restoration in Black Men and Women

Hair Restoration in Black Men and Women: Proper Selection is Essential

In general, there are three ways to remove hair from the back of the scalp in the course of a hair transplant:

1. Follicular unit extraction (FUE) 

2. Robotic follicular unit extraction (R-FUE or ARTAS)

3. Follicular unit strip harvesting (FUSS)

Each method can give great results and there are advantages and disadvantages of each. Men who plan to shave their scalp in the future prefer the FUE method because a linear scar is not seen.  

What is the best method of donor removal in Black Men and Women?

For most black women in my practice, strip method is superior. The grafts are easily removed and in the properly selected patient, the area heals very nicely. Shaving of the back of the scalp is not required and we have access to 500-2500 healthy grafts.

For most black men in my practice, a preference for FUE is seen. However, not all black men are good candidates for FUE. There are several factors that influence whether someone is a good candidate for FUE.  One of these is the shape and curl of the patient's hair follicles.  It is much easier to extract hairs by FUE in men with straighter hair than men with curly hair.  The curlier the hair, the more difficult it is to predict the path that the hair follows under the scalp and the more likley these hairs are to be damaged by FUE.  We call this damaged 'transection.' Curlier hair is much more likely to be transected during FUE.

If I'm ever not sure if a patient is a good candidate for FUE, I will do a small test session and extract a few grafts and then examine the grafts under the microscope for evidence of 'transection.' If I can't be sure that I'll have nice grafts, I won't do an FUE procedure.  It doesn't happen very often, but certainly there are a small proportion of black men who are not good candidates for FUE by either manual FUE or ARTAS.

Traction alopecia : Should I get a hair transplant or not?

Traction alopecia : Is a hair transplant a good option?

Traction alopecia is due to pulling of hairs, usually along the front of the scalp. Traction alopecia affects women much more than men.  There are many treatments for traction alopecia including steroid injections, minoxidil and hair transplantation. How do we know which to recommend? Is one better than the other?

Sudden Traction Alopecia may grow back; long standing does not

In general, if hair loss has been present for a short period of time (weeks or months), then medical treatment with steroid injections or minoxidil is worth trying. If the hair loss has been present for an extended period (a few years or more), then the hair loss is generally permanent and the only means to restore hair in the area would be to do a hair transplant.

Hair Loss in the Crown: What are the options for men under 35?

Hair Loss in the Crown: Do we transplant men under 35?

I rarely perform a hair transplant in men with hair loss in the crown prior to age 35. Most hair transplant surgeons around the world have similar cut-offs, and a few of my colleagues would even push this to 40 years of age. The area of hair loss can expand leaving an unnatural look if the area is transplanted too early.

So what, then are the non-surgical options that can be considered to treat hair loss in the crown? 

OPTIONS FOR TREATING HAIR LOSS IN THE CROWN PRIOR TO AGE 35.

1. Finasteride.

Finasteride (sold under name Propecia as well as generics) helps about 90 % of men stop hair loss. A proportion of men improve their hair as well. Side effects include decreased libido, erectile dysfuntion, mood changes, enlargement of breast tissue. read more.

 

2. Minoxidil

Minoxidil (sold under many brands including popular Rogaine) helps 20 % or more of men maintain their hair. A small proportion will also see improvement. It works best in the earliest stages of hair loss, especially in men with less than a 10 cm diameter area of hari loss. read more. 

 

3. Platelet rich plasma

Platelet rich plasma involves removing one's own blood and injection that nutrient rich PRP back into the scalp. The procedure is safe and helps up to 50-70 % of men. Platelet rich plasma therapy is emerging as an important treatment consideration for young men with hair loss who may not yet be surgical candidates. Some of US colleagues are also investigating the use of ACell/Matristem with PRP, but unfortunately ACell is not approved in Canada. read more.

 

4. Low level laser therapy (LLLT)

LLLT involves use of red light lasers to stimulate hair growth. Studies show that they  promote improvements in some users.  read more. 

 

5. Copper peptides.

Viewed as an alternative to minoxidil, phase 2 FDA studies showed that copper peptide based technology (including products like Tricomin) promote hair growth in some users. I encourage patients to use with minoxidil.

Platelet rich plasma for treatment of alopecia areata: How good is it?

Platelet rich plasma (PRP) for treatment of alopecia areata

Platelet rich plasma or “PRP” treatment has been around since the 1990’s, but is increasingly finding application in various parts of medicine. PRP to treat hair loss is increasingly popular and current evidence suggests it helps 50-70 % of patients with genetic hair loss. Hair transplant surgeons are increasingly interested in using PRP during surgery.  We too are now offering PRP as a means to augment currently available treatment modalities for hair loss.

PRP involves obtaining a patient’s blood and isolating a component of the blood cells called platelets and the rich nutrients that surround the platelets called platelet rich plasma. It’s this platelet rich plasma that can stimulate hair growth in some patients.  PRP is known to contain over 20 different growth factors.

Does PRP also help patients with alopecia areata?

Although PRP has been studied in genetic hair loss, it’s role in alopecia areata had not been carefully studied. Researchers from Italy and Israel set out to study the benefit of PRP in patients with alopecia areata and compare how well the treatment worked compared to the standard treatment – that being steroid injections.

The researchers studied 45 patients with alopecia areata. After 12 months of observation, 60 % of patients treated with PRP had complete remission compared to 27 % of patients treated with steroid injections. Furthermore at 6 months after treatment, 38 % of patients receiving steroid injections had relapse compared to none of the patients form the PRP group. At 12 months, 71 % of patients in the steroid injection group had a relapse compared to only 31 % in the PRP treatment group.

This is an tremendously exciting study. PRP has very little side effects because it is the patient’s own blood.  PRP not only has growth promoting effects but has anti-proliferative effects as well. Both of these effects are likely extremely important for effective treatment of alopecia areata

Further large studies are needed to better understand the role of PRP in alopecia areata.  This initial study gives us new hope that this indeed may be a good treatment modality.

Reference

Trink A et al.  A randomized, double-blind, placebo- and active-controlled, half-head study to evaluate the effects of platelet rich plasma on alopecia. British Journal of Dermatology 2013; 169: 690-94

Alzheimer's drugs and hair loss

Do Alzheimer's drugs  cause hair loss?

Today, I had a great conversation about Alzheimer's medications with a fellow passenger in the airport so I thought I'd share a few interesting points about these drugs.

In the year 2014, there is no cure for Alzheimer's disease. However, there are five drugs approved by the FDA to treat the symptoms of Alzheimer's. Donepezil, galantamine, tacrine and galantamine are called "cholinesterase inhibitors" and the fifth drug memantine is an NMDA receptor antagonist.  According to Litt's Drug Eruption Reference Manual - a key reference for drug side effects -  these drugs cause hair loss in approximately 1 % or less of users. So they are not common causes of hair loss, but they are on the list.  Hair loss typically starts 3-6 months after starting and the individual experiences an increase in noticeable hair shedding. 

The five FDA approved Alzheimer's drugs

1. Donepezil (marketed under brand name Aricept, approved to treat all stages of Alzheimer's disease) - causes hair loss in less than 1 % of users.

2. Rivastigmine (marketed under brand name Exelon, approved to treat mild to moderate Alzheimer's) - causes hair loss in 1 % of users

3. Galantamine (marketed under the brand name Razadyne, approved to treat mild to moderate Alzheimer's disease) - the proportion of people who develop hair loss is still not clear

4. Tacrine (marketed under Cognex was the first cholinsterase inhibitor but rarely prescribed today) - causes hair loss in less than 1 % of users

5. Memantine (marketed under Namenda, approved to treat mild Alzheimer's disease) - causes hair loss in less than 1 % of users.

Conclusion

Overall, hair loss is an uncommon side of these new Alzheimer's drugs, but can occur. Hair loss typically starts 3-6 months after starting the drug.  Stopping the drug can reverse the hair loss, but sometimes this is not practical if it is thought that the drug is helping with memory and cognition.

Smoking and hair transplantation

Smoking and hair transplantation

There are many ways to do a hair transplant. At meetings, we debate about which ways are best. Donor harvest with strip methods, FUE, ARTAS.  Recipient site creation with needles, blades.   However, there's one thing we don't debate about: smoking is detrimental to hair transplants.

Of course lots of patients who smoke have successful hair transplants.   However, a small proportion have poorer growth. Nicotine decreases blood flow to the scalp by constricting blood vessels. The ability of blood to carry oxygen is reduced on account of the carbon monoxide in the blood. These factors increase the chance of poor wound healing and increase the chance of infection, scarring and overall poor growth. 

Minimal recommendations for hair transplant patients who smoke.

When it comes to stopping smoking, it's clear that the longer one abstains the better. Stopping one month before is better than one week before and two months is probably even better. The optimal times have yet to be thoroughly studied. In general, stopping smoking at least 1 week prior to hair transplant surgery and restarting no sooner than 2 weeks after the procedure provides appears to provide significant benefit.

Testosterone therapy in men considering hair transplants : Do I worry about more than just hair loss?

Testosterone therapy in men considering hair transplants : 

There is a marked rise in the number of my male hair loss and hair transplant patients using testosterone therapy, especially men over 50.  Testosterone is also used at increasing rates in younger men as well.  Testosterone therapy is used in healthy men to counteract age-related reduction in serum testosterone and the diminished strength and physical function that accompanies the reduced testosterone.

Testosterone therapy and hair loss

In men with genetic hair loss, testosterone, as well as other androgen hormones (like anabolic steroids), have the potential to accelerate genetic hair loss. Some men notice increased hair shedding en route to developing worsening hair loss.  In my patients who use testosterone, we need to carefully plan for possible future hair loss. A hair transplant patient using testosterone may need a more conservative approach than a hair transplant patient not using testosterone.  A careful discussion and plan needs to be put in place. 

Testosterone therapy and heart attacks

Several studies have addressed the concern that testosterone therapy might lead to adverse cardiovascular outcomes.  In fact,  a small randomized trial of testosterone gel on muscle function in men 65 years of age or older was discontinued in 2010  because there were too many cardiovascular events in the group of men using testosterone.  A review of a number of  trials in predominantly older men also showed that men using testosterone had increased risk of cardiovascular problems. In addition, a recent study of men average age over 60 reported an excess of death and cardiovascular disease in those being treated with testosterone therapy.  In two studies, it appears that the risk of heart events (heart attacks, etc) starts very soon following starting therapy. 

Study findings of a new research study

A new study published this week in the Journal PLOS ONe showed that  older men, and in younger men with pre-existing diagnosed heart disease, the risk of having a heart attack after starting testosterone therapy is  substantially increased.

In fact, in men 65 years and older, the researchers observed a two-fold increase in the risk of heart attacks in the first three months after starting testosterone therapy. The risk actually  declined to baseline from month 3 to 6 in those who stopped therapy again.  The researchers also showed that among younger men with a history of heart disease, there was a two to three-fold increased risk of heart disease in the first three months after starting testosterone and no increased risk in younger healthy men without history of heart disease. 

Conclusion

While my main focus is on my patient's hair, I consider it critically important to be aware of the broad scope of medical research. My patients often need to make decisions about starting testosterone therapy for their physical health vs not starting on account of hair loss. At least 2-3 times daily in my hair transplant practice I have these important discussions. The scientific data are showing us time and time again that testosterone therapy increases the risk of heart attacks and other cardiovascular problems in men with a history of heart disease.

REFERENCES

1. Finkle et al. Increased Risk of Non-Fatal Myocardial Infarction Following Testosterone Therapy Prescription in Men. PLOS one. Published Jan 29

2. Hensen LG, Chang S (2010) Health research data for the real world: The Thompson Reuters Marketscan Databases. White paper. Ann Arbor, MI.

3. Baillargeon J, Urban RJ, Ottenbacher KJ, Pierson KS, Goodwin JS (2013) Trends in androgen prescribing in the United States, 2001 to 2011. JAMA Internal Medicine: 1–2.Page ST, Amory JK, Bowman FD, Anawalt BD, Matsumoto AM, et al. (2005) Exogenous testosterone (T) alone or with finasteride increases physical performance, grip strength, and lean body mass in older men with low serum T. J Clin Endocrinol Metab. 90: 1502–1510.  

4. Xu L, Freeman G, Cowling BJ (2013) Schooling CM (2013) Testosterone therapy and cardiovascular events among men: a systematic review and meta-analysis of placebo-controlled randomized trials. BMC Med 11: 108. doi: 10.1186/1741-7015-11-108.

5. O'Connor A (2013) Men’s use of hormones on the rise. New York Times.

6. Basaria S, Coviello AD, Travison TG, Storer TW, Farwell WR, et al. (2010) Adverse Events Associated with Testosterone Administration. New England Journal of Medicine 363: 109–122. 

7. Seeger JD, Walker AM, Williams PL, Saperia GM, Sacks FM (2003) A propensity score-matched cohort study of the effect of statins, mainly fluvastatin, on the occurrence of acute myocardial infarction. Am J Cardiol 92: 1447–1451.

8. Vigen R, O’Donnell CI, Barón AE, Grunwald GK, Maddox TM, et al. (2013) ASsociation of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels. JAMA 310: 1829–1836. doi: 10.1001/jama.2013.280386.

9. Bremner WJ (2010) Testosterone Deficiency and Replacement in Older Men. New England Journal of Medicine 363: 189–191.

10. Jackson G, Montorsi P, Cheitlin MD (2006) Cardiovascular safety of sildenafil citrate (Viagra): an updated perspective. Urology 68: 47–60. doi: 10.1016/j.urology.2006.05.04

Hair loss treatment: another giant step forward

New hair loss research findings

This week a major breakthrough was announced by researchers at the University of Pennsylvania and published in one of the world's top research journals, Nature Communications.   

 

How do you make a hair follicle anyways?

As a bit of  background, it's important to understand how to make a hair follicle. You need to mix several specific cells together and then let nature do the rest. To make a cheese sandwich, you need cheese and bread. The more cheese and bread you have, the more sandwiches you can make. To make a strawberry sundae you need strawberries and ice cream. The more strawberries and ice cream you have, the more sundaes you can make.   To make a hair follicle, you need 2 things - epithelial stem cells (ingredient number 1) and dermal papillae (ingredient number 2).  And if you find a way to generate massive amounts of each, you'll find yourself with massive amounts of hair follicles - and a potential ability to treat hair loss.

Key Research Findings

The researchers from the University of Pennsylvania have shown, for the first time,  a method to generate large numbers epithelial stem cells - ingredient number 1 in the two part mixture to make a hair follicle.  When the epithelial stems cells were mixed with other cells they formed skin cells and hair follicles. The next goal now is to figure out a way to make massive amounts of dermal papillae (ingredient number 2)

Conclusions:

These are exciting studies for everyone to pay attention to - be they individuals with hair loss, hair loss specialists or hair transplant surgeons.  These studies provide a potential recipe or approach to generate massive large numbers of human epithelial stem cells for new treatments for hair loss. It's important to be aware that this study was done in mice and it's not clear if this an be easily replicated or translated to humans, but it's a (very, very, very) big leap.  Stay tuned.

REFERENCE

Yang et al. Generation of folliculogenic human epithelial stem cells from induced pluripotent stem cells. Nat Commun. 2014 Jan 28;5:3071. doi: 10.1038/ncomms4071.

 

Treating seborrheic dermatitis in androgenetic alopecia: Make it a part of the plan

Treating seborrheic dermatitis in male pattern balding 

Seborrheic dermatitis is a common flaky scalp condition that affects about 1 out of every 15 people. I describe the condition 'seborrheic dermatitis' to my patients as being a distant cousin of 'dandruff.' Individuals with seborrheic dermatitis have red, flaky, greasy scalps. The flakes may be yellow or white. When it's mild, most don't even know they have seborrheic dermatitis. Others notice a bit of itching, especially if they don't wash their hair every day. Seborrheic dermatitis, like dandruff, is influenced to a large degree by a yeast that lives in our scalp called Malassezia. But this yeast isn't the whole story, and a variety of genetic, environmental and hormonal factors seem important. 

Is seborrheic dermatitis harmful? If not, why treat it?

For the most part, seborrheic dermatitis is not harmful.   I pay attention to seborrheic dermatitis in both my hair loss patients and my hair transplant patients and treat it if the condition is present. I do this for a couple of reasons:

1. Poorly controlled seborrheic dermatitis increases the proportion of hairs that are in the resting phase of the hair cycle (telogen phase). If we want to build density and drive improvement, we need growing hairs!  While seborreheic dermatitis usually doesn't cause hair loss or shedding, poorly controlled seborrheic dermatitis can. In patients with many miniaturized hairs undergoing hair transplant procedures, I believe that encouraging these hairs to be in the growing phase rather than the telogen phase, reduces 'shock loss.' I advise using an anti-dandruff shampoo (see below) three or four times per week for 6 weeks leading up to the transplant and then resuming 2 weeks after the hair transplant

2. Treating seborrheic dermatitis with anti-dandruff shampoos may actually help hair growth. I am reminded of two studies  - one from 1998 and one from 2003 - which showed the zinc pyrithione shampoo as well as ketoconazole shampoo actually helped promote hair growth in men with androgenetic alopecia.  Whether the ingredients themselves are hair growth promoting or whether getting rid of the yeast reduces inflammation that helps drive hair growth is not 100 % clear, but it seems that the latter is more likely.  Regardless, I recommend treating seborrheic dermatitis aggressively when it's present. 

Treatment of seborrheic dermatitis

Fortunately, treating seborrheic dermatitis is usually simple, with any of the commercially available shampoos:

a) zinc pyrithione (i.e. Head and Shoulders and others)

b) selenium sulphide (i.e. Selsun Blue and others)

c) ketoconazole (i.e. Nizoral and others)

d) tar-based shampoos (i.e. T-gel and others)

e) ciclopirox olamine (i.e. Stieprox and others)

References

1. Pierard-Franchimont et al. Ketoconazole shampoo: effect of long term use in androgenetic alopecia. Dermatology 1998; 196; 474-7

2. Berger et al. The effects of minoxidil, 1 % pyrithione zinc and a combination of both on hair density: a randomized controlled trial. Br J Dermatol 2003; 149: 354-62

Regrowth in early scarring alopecia: Do you see what I see

Does hair density in scarring alopecias ever improve?

 

1.The hair loss that occurs in most scarring alopecias is usually permanent

For the most part, the hair loss that occurs in a group of conditions known as scarring alopecias is permanent. Medical treatment is administered to stop the hair loss or slow the hair loss. Once the disease is stable, a hair transplant can be done to add density to the areas of hair loss. We are increasingly transplanting patients with scarring alopecia.

 

2. Treating early-staged scarring alopecias aggressively provides chance for regrowth

Hair regrowth in aggressively treated scarring alopecia. While total regrowth might not occur, regeneration a few hundred hairs will enable us to restore density with a hair transplant down the road - using far less grafts.

If aggressively treated, some scarring alopecias can not only be brought under control but some of the hairs that  were injured but not completed destroyed can produce a new hair.

Take a look at the high magnification photo of a patient with early scarring alopecia who is under aggressive treatment. Three months into treatment, she is sprouting new hairs.  You can see one of these new hairs right in the middle of the photo.

While we will need to wait to see just how much regrowth will occur, this is an important observation. Even if we can't completely reverse the disease, sprouting a few new hairs will limit the overall visibility of the scalp and help provide better camouflage. The patient hopes to have a hair transplant someday, and by regenerating a couple hundred hairs, we'll need to use less hairs when it comes to performing the hair transplant down the road.

Stimulating Hair Growth with Scalp Massage - Completely Useless?

Stimulating Hair Growth with Scalp Massage

For the most part, (perhaps 99.9 %), the concept of stimulating hair growth with scalp massage is a useless concept. But I'd hate to see the concept disappear completely.  My waiting room magazines are filled with the 'expert' beauty tip of how massaging and brushing can stimulate hair growth.  Hundreds of thousand of women (and men) around the world are brushing and massaging to get more blood  in hopes it does something positive. I can assure you with 100 % certainty, that small numbers of people are also standing on their heads. Does it help? 

It doesn't.

But why don't I want this erroneous concept to disappear completely? Why would I want seemingly mythical-like unfounded non-truths to permeate the world's health, beauty and fashion industry's magazines?

Well, there could be a micro-fraction of truth behind the concept.

Genetic hair loss is associated with decreased blood flow

Genetic hair loss IS indeed associated with a decreased blood flow to the scalp. But what we know in the year 2014 is really whether increasing blood flow could do anything beneficial. 

Genetic hair loss is also known as androgenetic alopecia (AGA). It occurs in 50 % of men by age 50 and 35 % of women. The key process in genetic hair loss is that hair follicles get skinnier or thinner. The medical term for this phenomenon is 'miniaturization."  Is some ways, it makes good sense that smaller thinner hairs need less blood flow. Why would a 25 micron diameter hair follicle need as much micronutrients, growth factors and cytokines to keep them growing as a 85 micron big 'original' size hair follicle not affected by genetic hair loss.

Minoxidil and low level light therapy (LLLT) increase blood flow

While attempts to stimulate blood flow with brushing and massaging of the scalp are useless, what we don't really know if increasing blood flow to the scalp on a more regular basis or to deeper levels of the scalp could do something positive. The hair loss treatment minoxidil and hair loss treatments with low level light therapy ARE associated with increasing blood flow to the scalp. Whether this is the 'reason' behind their growth promoting effect or just a 'coincidence' remains to be worked out.

For now, I'll shake my head , laugh and cover my eyes every time I read that massaging the scalp is good for hair, but at the same time I'll hope the next month's issues of the top magazines still contain the same bizarre, unfounded myths.

We still need to understand the role of blood flow to the scalp in genetic hair loss and the role of growth factors and cytokines that influence the reduced blood flow in balding scalps.

Platelet rich plasma - more evidence of benefit

Platelet rich plasma - more evidence of benefit

Platelet rich plasma is increasingly be used in hair restoration  and in hair loss to give a "boost" to current therapies.  Data continues to emerge of benefit under certain circumstances. Many hair transplant surgeons and hair loss physicians in general have added it to their treatment plans for patients.

Today I'd like to tell you about a mouse study rather than a human trial. But it's an interesting study and points to benefit for PRP in this setting.

Researchers from China set out to study how PRP helps hair follicles develop.  To do this, they mixed up dermal papilla cells and epidermal cells in various concentrations of human PRP and placed these cells on the backs of mice (called nude mice) to try to induce hair follicles to grow. Although the dermal papilla cells in this study were from mice, the PRP was from humans.

What were the results of the PRP study?

The study showed that higher concentrations of PRP caused the hairs to form faster on the backs of these mice. Higher concentrations of PRP also caused a greater density of hair follicles to form. 

Comment

Specific models to study the role of PRP are important. This study shows that PRP is beneficial to the formation of hair follicles in this mouse model.  This experimental model could serve as a useful model in the future.

Reference

Miao Y et al. Promotional effect of platelet rich plasma on hair follicle reconstitution in vivo. Dermatologic Surgery 2013; 39: 1868-1876

The 60 second hair count

What is normal shedding? How do we assess normal daily shedding?

It's often said that we lose between 50 and 100 hairs per day. But is this accurate? There has been very few clinical studies that examined precisely the rates of normal shedding. For some it's 15, for others is 53. For others it's 76.

The '60 second hair count'

This assessment too was introduced by US researchers  in 2008. They asked men age 20 through 60 to comb their hair for 60 seconds for 3 consecutive days before shampooing (starting at the top and combing forward).  The comb used in the study was the Cleopatra 400 comb from Krest combs and is shown in the photo below. The hair was combed over a towel or pillowcase to collect the hairs.

What were the results?

Participants shed an average of 10 hairs, and findings were similar in men 20-40 compared to men 40-60. 

TIPS ON PERFORMING THE 60 SECOND HAIR COUNT

1.  Before you plan to shampoo your hair, put down a white pillow case or sheet of white paper on the counter

2. Using the same comb, brush your hair starting at the crown (top of the scalp) and move forward to the forehead. Use one stroke for the top, one for the right side and one for the left side. Each stroke should be 1 second part for a total of 60 strokes

3. Collect the hairs on the pillowcase of sheet of paper. Count the number. If you have been asked to bring them into the office. Put them in a zip lock freezer bag, write the data on the bag,  and bring them into the office 

4. Repeat the procedure before you shampoo your scalp again - for a total of three consecutive shampooings

Reference

Wasko et al. Standardizing the 60 second hair count. Arch Dermatol 2008; 144: 759-62

Transplanting Stage V and VI hair loss - how long to wait between session?

Transplanting Stage V and VI hair loss

Men with advanced hair loss may wish to cover both the front and the top of the scalp. if the area is large, two transplant session may be required to achieve adequate coverage. Many patients want to know how long to wait between sessions and should they do the front or top first?

Should the front or top be transplanted first?

There is no right answer, but 95 % of my patients start with the front and I usually encourage this. The front of the scalp is so important to framing the face. In fact, sometimes all that is needed for some patients is just to add a small density of hairs to the front and middle of the scalp and they achieve a huge difference in their look.

Rarely, a patient will want to start with the top or 'vertex'. Provided the patient is over 35 this is sometimes a reasonable plan. Some men want to leave some degree of thinning in the front but fill in the back. For these men, it's the hair loss in the crown that really bothers them. That's a good plan for these men.

How long to wait between sessions?

Generally I recommend waiting 9-12 months for a second surgery. By this time hair has grown in to significant levels and patients can really see the coverage. And because the front is so important in the overall 'look', some men will feel that their changes are sufficient to hold off on adding more hair in the crown.  In addition, it becomes much easier to see where to add new hairs by waiting a few more months. 

For men having strip surgery, waiting to 9-12 months allows scalp exercises to be started once again to help with laxity in the donor area.

Using the donor area wisely in hair transplantation: mathematics matters

Some men "destined" to develop with Hamilton Norwood class VI balding may only have 4000-5000 grafts available to move in their entire lifetime

Using the donor area wisely in hair transplantation

How valuable is a follicular unit nowadays?  What is the real cost of a transplant? 5 dollars per graft? 7 dollars per graft? 10 ? 3? Well, follicular units are still priceless because once they are gone the body can't regenerate them. 

Someday, scientific advances might allow us to have an infinite supply of donor hair. For now, however, it's finite. Because donor hair is finite we always need to keep in mind one important principle: to use it wisely.

One of my favourite hair transplant papers from 2013 was a study by Dr. Walter Unger and colleagues. They  published a nice study looking at how many grafts the 'average' person has in their donor area. For someone destined to be Hamilton Norwood scale V or VI it ranges from 4200 to 7900 grafts. These numbers are important to keep in mind for reasons I'll describe.

EXAMPLE 1:

Consider a 33 year old man with frontal hair loss. When he meets in the office, it's clear that he is at high risk for further hair loss. He does not want to consider any hair loss medications to stop or prevent hair loss out of fear of side effects. In the worse case scenario he's destined to be a Hamilton Norwood VI with low density donor when he's 55.  To bring his hair back to the original density he once had at 18 he would need 3000 grafts packed at high density (where the survival of the grafts is possibly 70%). However, to significantly improve his density, make him look and feel great about his hair, he needs 2400 grafts (where the survival of grafts is likely 95 %). 

Which of the following do we do?

SITUATION 1

Use 3000 x 70% survival  = 2100 growing grafts in final result; 900 wasted;

Total grafts 'left' in the donor bank for future transplants = 1000 grafts

SITUATION 2

Use 2400 x 95 % survival = 2280  growing grafts in final result;  120 wasted

Total grafts left in the donor area bank for future transplants = 1600 grafts

ANSWER:

Clearly, there is a slight preference for Situation 2. The reality is that with 2100 growing grafts or 2280 growing grafts that patient will have an improved look.  With situation 1 (and unrealistic expectations), the patient may feel that he didn't quite get the density he was hoping for but will still have a nice improvement. However, on account of the potentially poorer growth of densely packed grafts, he'll have unnecessarily used up or wasted many hundreds of grafts.  This won't make any difference to the patient unless he wants to have a second transplant down the road (see example 2).

EXAMPLE 2: 

The same man as in the above example returns to the office in the year 2030. He has hair loss in the crown and would like another transplant. You estimate he needs 2000 grafts for full dense coverage but 1500 grafts to give him a nice coverage so that the scalp can't be seen.

Which option (Situation 1 or Situation 2) was the best option for the original first transplant session at age 33 ?

ANSWER:

It comes as a surprise to many that the best option is situation 2. By using up fewer grafts, we actually have a better outcome for transplant session 1 at age 33 (because of the higher survival rate of grafts) and now in year 2030 we have more grafts available to take. Our patient not only looks better in his mid 30s with careful planning but he looks better in his mid 50s

Comment

In hair transplant surgery, mathematics matters. The density of the recipient area that we plan out matters. The predicted density and amount of donor area in the future matters. The type of hair, quality, calibre and curl matters. The decision on FUE vs strip matters. Careful planning can help a large proportion of patients maintain good scalp coverage throughout their life. The price of a follicular unit is priceless as they are limited and can't be replaced.

Should I use minoxidil (Rogaine) after my hair transplant?

Should I use minoxidil (Rogaine) after my hair transplant?

Many hair transplant patients want to know if they should use minoxidil after their hair transplant. For many patients, it's usually a good idea. Use of minoxidil after a hair transplant can do two things:

1. speed of the rate that the transplanted hairs start growing by about 1 month.

2. reduce the chances of ongoing hair loss in existing hairs (non transplanted hairs)

in 1987, Dr. Kassimir published a study in the Journal of the American Academy of Dermatology. He reported his findings with 12 patients who used minoxidil after their hair transplant. 2 of the 12 patients didn't lose the transplanted hairs ( a finding we normally see at 3 weeks) and 2 of the patients started regrowing hair at 4 weeks (instead of 3 months that we normally see)

Advice to patients regarding minoxidil after hair transplant

I don't advise minoxidil to all my patients. For some it's impractical. For some, they do not want to use and this was important in their decision to get a transplant in the first place. But for those who we do decide to start minoxidil, I advise starting (or restarting it) 5 to 7 days after the hair transplant. The decision on how long to continue is also important. For preventing loss of existing hair, clearly it needs to be continued long term. However, for boosting growth of transplanted hairs, it can be continued 4 to 6 months. 

Reference

Kassimir JJ. Use of topical minoxidil as a possible adjunct to hair transplant surgery.  A pilot study. Journal American Academy of Dermatology 1987; 16: 685-7

Preventing chemotherapy induced hair loss - new options around the corner

Preventing chemotherapy induced hair loss 

60 % of patients receiving chemotherapy lose their hair and most grow back hair within  6 months. I've evaluated dozens and dozens of patients in the last year who didn't grow their hair back completely after chemotherapy treatment. This phenomenon is called  "permanent chemotherapy induced alopecia" (PCIA). We have also successfully performed hair transplants on a number of patients with PCIA moving hair from thicker areas to thinner areas. Today, I want to discuss the topic of both chemotherapy induced hair loss and permanent chemotherapy hair loss and introduce the concept of "scalp cooling" which may soon be granted FDA approval as a treatment.

Chemotherapy Induced Hair Loss

60 % of cancer patients develop hair loss after chemotherapy. Massive shedding beginning 1-3 weeks after chemotherapy. The hair loss is generally complete at 1-2 months and hair growth occurs 3-6 months later. Hair loss from chemotherapy is extremely distressing. Studies have shown that 47 % of female cancer patients consider hair loss as the most traumatic aspect of treatment and 8 % would decline chemotherapy on account of the possibility of developing hair loss.

Does hair always grow back after chemotherapy?

Recently, it has been shown that not all patients regrow their hair after chemotherapy. Some medications such as taxanes (for breast cancer), busulfan (for blood cancers) and cisplatin (for many cancers) may be associated with some patients not growing all their hair back. This is called permanent chemotherapy induced alopecia (PCIA). I explored this in a previous blog. 

Can hair loss be prevented from chemotherapy?

Certain drugs such as minoxidil can shorter the duration that the hair loss lasts and reduce the severity of the hair loss. Other drugs are being explored, including a drug called AS101. 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 and has been shown in 6 of 7 studies to reduce hair loss. 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. Check out the links to read more. The two scalp cooling agents to be on the lookout for are the Penguin Cold Cap and Dignicap.

Comment :

Hair loss from chemotherapy is extremely distressing. Scalp cooling offers a new option to reduce the chances of hair loss and I'm really interested to see how these studies make out in the US.  Really good studies are being done and may lead to their approval soon if these US studies show them safe and effective.  It will be important to determine if scalp cooling reduces the chance of PCIA - permanent chemotherapy hair loss. It's very distressing to patients when the hair doesn't return to its original density after cancer treatments are done. We are seeing more and more women with PCIA in our Toronto office and sometimes hair restoration is an option but sometimes there is too little hair density to make it a good option.  Scalp cooling may help prevent not only chemotherapy hair loss but reduce PCIA as well.  

Jeff Donovan MD

Reference

1. McGarvey et al 2001         2. Mundstedt  et al 1997    3. Batchelor et al 2001

Dutasteride and Finasteride: New data suggests no Link with breast cancer in men

Dutasteride and Finasteride: Do they cause breast cancer?

Finasteride (Propecia) and dutasteride (Avodart) are prescribed for the treatment of male pattern baldness. Many of my male hair transplant patients receive finasteride or dutasteride in order to help reduce the progression of balding in existing hairs.  

Finasteride and dustasteride belong to a group of drugs called "5 alpha reductase inhibitors." They block the enzyme 5 alpha reductase and decrease the levels of the potent androgen hormone DHT (dihidrotestosterone). In addition to reducing DHT, the drugs increase the levels of estrogen slightly which has raised questions from physician and researchers around the world as to whether these drugs increase the risk of breast cancer in men.

US researchers set out to examine the relationship between the use of 5 alpha reductase inhibitors and male breast cancer. They studied men using the higher 5 mg dose of finasteride used in prostate enlargement (rather than the 1 mg dose used in hair loss) and the 0.5 mg dose of dutasteride.  They looked at the use of these drugs in 339 men with breast cancer and 6,780 men without breast cancer.

What were the findings and conclusions from the study?

The authors did not find an association between using 5 alpha reductase inhibitors and the development of breast cancer in men. Overall, the authors concluded that the "development of breast cancer should not influence the prescribing of 5 alpha reductase inhibitor therapy."

Reference

Bird ST et al. Male breast cancer and 5 alpha reductase inhibitors finasteride and dustasteride. J Urology; 190:1811-4

Low light laser therapy (LLLT) for hair loss

Low light laser therapy (LLLT) for hair loss

Low-level light therapy (LLLT) has been used in the treatment of genetic hair loss for a few years now.  Some previous research studies with LLLT devices showed that these devices can increase hair density or hair caliber in a small target area following treatment,  but other studies did not. In some studies, this translated into patients or clinicians detecting an improvement in hair density with use of LLLT, whereas in other studies these improvements were not seen.

New LLLT study

A study from South Korea evaluated the efficacy and safety of a LLLT device that is worn on the scalp as a helmet. (Oaze, Won Technology, Daejon, Korea) The researchers conducted a 24-week randomized, double-blind study with use of a sham device.  The primary endpoint of the study was the change in hair density in a 70- mm2 target area from baseline to 24 weeks. Secondary endpoints included changes in the hair shaft size and the satisfaction of the subjects.

A total of 29 subjects finished the study, including 15 in the LLLT group and 14 using the placebo device.  The device was safe  and there was no documentation of severe adverse reactions.  Subjects using the LLLT device had a greater increase in hair density (approximately 19 hairs/cm2) and thickness  (approximately 9 μm) compared to those using the sham device.  Investigators detected a statistically significant increase in hair density in those using the LLLT device compared to those using the sham device. However, there was no difference in subjects’ perception of improvement or satisfaction ratings between LLLT and sham users.

Comment: LLLT users didn’t feel that his or her hair looked better with use of the device. Further well designed studies are need as we continue to explore how well LLLT therapy works for patients with hair loss.

Reference

Kim H et al. Low-Level Light Therapy for Androgenetic Alopecia: A 24-Week, Randomized, Double-Blind, Sham Device-Controlled Multicenter Trial. Dermatol Surg 2013; 1177-83.