Hair transplantation: Basic overview.

Modern hair restoration surgery is based on a technique known as follicular unit transplantation, in which follicular units are the exclusive structures used as hair grafts. In Part 1 of this 2-part review, we describe how the techniques employed in hair transplantation have evolved into their present forms. Anatomic concepts of specific relevance for dermatologists are discussed, including the distribution and ex vivo morphology of scalp follicular units. Male androgenetic alopecia and female pattern hair loss are the most common reasons for hair loss consultations with dermatologists and will be the primary focus of this review. However, because not all hair disorders are suitable for transplantation, this review will also describe which scalp conditions are amenable to surgery and which are not. Guidelines are provided to help dermatologists better define good and bad candidates for hair transplantation. Other conditions for which hair transplantation surgery is indicated are reviewed.

CME article Part II. Hair transplantation: Surgical technique.

The second part of this hair transplantation review concentrates on the technical aspects of the surgery. First, we review the 2 main local anesthetics used in hair transplantation, lidocaine and bupivacaine, how to achieve long-lasting local anesthesia, and what techniques can be used to minimize the pain associated with anesthetic infiltrations. Second, we review the 2 donor harvesting techniques currently used: strip harvesting follicular unit transplantation and follicular unit excision. The technical aspects of each technique are described in detail, along with their advantages and disadvantages. Third, the different methods of graft implantation currently used by the majority of hair surgeons are discussed, including premade sites and stick-and-place and the use of tools such as implanters. Fourth, postoperative care, expected results, and the main complications involved in hair transplant surgery are reviewed.

Platelet-Rich Plasma as a Treatment for Androgenetic Alopecia.

BACKGROUND: Platelet-rich plasma (PRP) treatment may encourage hair growth by promoting cellular maturation, differentiation, and proliferation. OBJECTIVE: The objective of this study was to evaluate the effectiveness of PRP as a treatment for androgenetic alopecia (AGA). MATERIALS AND METHODS: A literature search combined with meta-analysis was used to calculate the overall standardized mean difference (SMD) in hair density in patients treated with PRP injections in comparison with baseline and placebo treatment. Chi squared analysis and Fisher exact test were used to investigate variation in protocols. RESULTS: The overall SMD in hair density was 0.58 (95% confidence interval [CI]: 0.35-0.80) and 0.51 (95% CI: 0.23-0.80, p < .0004) in favor of PRP treatment when compared with baseline and placebo treatment, respectively. CONCLUSION: Platelet-rich plasma is beneficial in the treatment of AGA. It is recommended that 3 monthly sessions of PRP (once monthly ×3 treatments) be used followed by a 3- to 6-month maintenance period.

Calf Augmentation and Reshaping with Autologous Fat Grafting.

BACKGROUND: Despite multiple advantages of fat grafting for calf augmentation and re-shaping over traditional silicone calf implants, few reports have been published. OBJECTIVES: To report our technique and results with autologous fat grafting for calf augmentation and reshaping. METHODS: A retrospective review of the senior author's (JEV) experience with autologous fat grafting for calf augmentation was performed. Medial and lateral calf augmentation was accomplished with injection of prepared autologous lipoaspirate intramuscularly and subcutaneously. RESULTS: Over a 5-year period, 13 patients underwent calf augmentation and reshaping with the described technique. Ten cases were bilateral (77%), and 3 cases (23%) were performed for congenital leg discrepancies. Mean 157 cc of prepared lipoaspirate was transferred per leg, with roughly 60% and 40% transferred into the medial and lateral calf, respectively. Four patients (31%) underwent a second round of autologous fat injection for further calf augmentation because they desired more volume. At mean 19.6 month follow-up, durable augmentation and improvement in calf contour was documented by comparison of standardized preoperative and postoperative photographs. CONCLUSIONS: Autologous calf fat grafting is a viable alternative to traditional implant-based calf augmentation for congenital calf discrepancies and the aesthetic pseudo-varus deformity. This technique provides results comparable to those obtainable with traditional methods. LEVEL OF EVIDENCE 4: Therapeutic.

Hair restoration surgery: the state of the art.

Hair restoration is a highly sophisticated subspecialty that offers significant relief to patients with hair loss. An improved understanding of the aesthetics of hair loss and cosmetic hair restoration, hair anatomy and physiology, and the development of microvascular surgical instrumentation has revolutionized the approach to surgical hair restoration since the original description. Additional elements that contribute to the current state of the art in hair restoration include graft size, site creation, packing density, and medical control of hair loss. The results of hair restoration are natural in appearance and are provided with a very high level of patient satisfaction and safety. This aspect of cosmetic surgery is a very welcome addition to a traditional aesthetic practice and serves as a tremendous source for internal cross-referral. The future of hair restoration surgery is centered on minimal-incision surgery as well as cell-based therapies.

Hair restoration complications: an approach to the unnatural-appearing hair transplant.

Hair restoration surgery has emerged as a leading technique for rejuvenation of the upper third of the face. Using contemporary techniques, the results are generally indistinguishable from the appearance of native scalp hair. Unfortunately, older techniques of hair transplantation did not produce this quality result. As a result, there are a considerable number of patients who bear the visual and psychological burden of older hair transplant techniques. In addition, there are regrettably additional patients who have similar unnatural hair transplant results from poorly performed procedures completed in recent time. Understanding the anatomic problems associated with the unnatural-appearing hair transplant is fundamental to the successful correction of the deformity. The most common problems associated with the unsatisfactory hair transplant seen in clinical practice are reviewed, and possible approaches to treatment are presented. The challenge for the hair restoration surgeon is to provide a level of expertise and honesty to these unfortunate patients to restore their appearance and self-confidence. Fortunately, a tremendous benefit for the patient can be achieved when a correction of the unsightly transplant is performed.

Psychological effect, pathophysiology, and management of androgenetic alopecia in men.

Androgenetic alopecia In men, or male pattern baldness, is recognized increasingly as a physically and psychologically harmful medical condition that can be managed effectively by generalist clinicians. This article discusses the clinical manifestations, epidemiology, physical and psychosocial importance, pathophysiology, diagnosis, and management of androgenetic alopecia in men. Androgenetic alopecia affects at least half of white men by the age of 50 years. Although androgenetic alopecia does not appear to cause direct physical harm, hair loss can result in physical harm because hair protects against sunburn, cold, mechanical injury, and ultraviolet light. Hair loss also can psychologically affect the balding individual and can Influence others' perceptions of him. A progressive condition, male pattern baldness is known to depend on the presence of the androgen dihydrotestosterone and on a genetic predisposition for this condition, but its pathophysiology has not been elucidated fully. Pharmacotherapy, hair transplantation, and cosmetic aids have been used to manage male pattern baldness. Two US Food and Drug Administration-approved hair-loss pharmacotherapies-the potassium channel opener minoxidil and the dihydrotestosterone synthesis inhibitor finasteride--are safe and effective for controlling male pattern baldness with long-term daily use. Regardless of which treatment modality is chosen for male pattern baldness, defining and addressing the patient's expectations regarding therapy are paramount in determining outcome.

Correcting problems in hair restoration surgery: an update.

Hair is an important emblem of health, youth, vigor, and vitality. The state of the art in hair restoration today is to create a result that is undetectable as a surgical hair transplant. Most procedures performed using previous techniques of plug hair trans-plantation are not aesthetically acceptable by today's standards, especially in the face of progressive hair loss, which can unmask previously camouflaged corn row plugs. A technique to reduce the plugs and recycle the grafts into smaller grafts is described. The recycled hair grafts can be combined with scalp lifting, scalp reductions, and occipital harvesting of grafts to improve the results of corn row-appearing hair trans-plants and other problems of surgical hair restoration.

The aesthetics of hair restoration.

The hairline and frontal hair volume are frequently overlooked aspects of attractive facial proportion and overall facial aesthetics. The author contends that patient benefit from hair restoration surgery is significant, and these procedures should be routinely considered as part of a complete facial rejuvenation.

The potential role of minoxidil in the hair transplantation setting.

BACKGROUND: Over the last decade surgical management of hair loss has become an increasingly popular and satisfying procedure for both men and women, as innovations in donor harvesting, graft size, and hairline design have resulted in consistently natural-appearing hair restoration. OBJECTIVE: In addition, a better understanding of the regulation of the hair-growth cycle has led to advances in the pharmacologic treatment of androgenetic alopecia. METHODS: Currently there are two U.S. Food and Drug Administration (FDA)-approved agents that promote hair regrowth: over-the-counter topical minoxidil solution for men and women and prescription oral finasteride tablets for men. In October 2001, a group of 11 international experts on hair loss and hair transplantation convened to review the physiology and effects of pharmacologic treatments of hair loss and to discuss the value of administering topical minoxidil therapy as an adjunct to hair transplantation. RESULTS: This article presents the key findings and consensus points among the participants, including their current use of pharmacologic treatments, strategies for optimal results both pre- and postsurgery, and the importance of realistic patient expectations and compliance. CONCLUSIONS: Based on the surgeons' clinical experience, the use of approved hair regrowth agents in hair transplant patients with viable but suboptimally functioning follicles in the region to be transplanted can increase hair density, speed regrowth in transplanted follicles, and complement the surgical result by slowing down or stopping further hair loss.

Hair transplantation in women: a practical new classification system and review of technique.

Alopecia in women is often overlooked as a major cosmetic problem. For women with hair loss, the psychological effects are often more severe than for men. Advances in modern hair transplantation have allowed successful hair restoration in many cases of female alopecia that might not have been possible to treat with older techniques. A classification of female hair loss patterns into 5 different categories is proposed. On the basis of these categories, a variety of techniques are demonstrated to restore alopecia. Careful preoperative patient evaluation, including analysis of the donor and recipient features, is emphasized. In addition, women's psychological reactions to hair loss and the expectations for hair restoration are discussed. (Aesthetic Surg J 2002;22:247-259.).