An international expert consensus statement focusing on pre and post hair transplantation care.

AIM: To achieve international expert consensus and give recommendations on best practices in hair transplantation surgery, focusing on pre- and post-transplantation care. METHODS: A modified Delphi method was used to reach consensus. An international scientific committee developed an 81-statement questionnaire. A panel of 38 experts in hair transplantation from 17 countries across 4 continents assessed the questionnaire. RESULTS: Two consensus rounds were carried out, with 59 out of 81 statements (73%) reaching consensus. Expert recommendations emphasize the correct selection of candidates for hair transplantation and the need for patients to have received adequate medical treatment for alopecia before transplant. Comorbidities should be assessed and considered while planning surgery, and an individualized plan for perioperative care should be drawn up before transplant. Certain medications associated with increased risk of bleeding should be withdrawn before surgery. Specific recommendations for post-transplantation care are given. After transplantation, patients should gradually resume their normal haircare regimen. Close follow-up should be carried out during the first year after transplant. CONCLUSIONS: This study presents numerous consensus-based recommendations on general aspects of hair transplantation, including candidate selection, medical therapy prior to transplantation, anesthesia, and resuming haircare after transplantation.

Angle of fetal head progression measured using transperineal ultrasound as a predictive factor of vacuum extraction failure.

OBJECTIVE: To evaluate the predictive value of angle of progression (AoP) of the fetal head for a failed vacuum delivery. METHODS: This was a prospective observational study that included women with a singleton pregnancy of ≥ 37 weeks' gestation, in cephalic presentation requiring vacuum extraction. Transperineal ultrasound was performed immediately before vacuum extraction, although AoP was measured on stored images after delivery. Vacuum extraction was defined as failed when the duration of extraction exceeded 20 min or the vacuum cup detached more than three times. We compared the demographic and ultrasound data of failed vacuum deliveries with those that were successful. The predictive value of AoP for failure of vacuum delivery was calculated. RESULTS: AoP was measured in 235 women. Vacuum extractions failed in 30 (12.8%) women (29/184 nulliparous and 1/51 parous) and resulted in 28 vaginal deliveries by forceps and two Cesarean deliveries. Median AoP was significantly lower in the vacuum failure group compared with those with successful vacuum delivery (136.6° (interquartile range (IQR), 129.8-144.1°) vs 145.9° (IQR, 135.0-158.4°); P < 0.01). As all but one failed vacuum extraction occurred among nulliparous women, the predictive value of AoP was calculated in this subgroup of women. The area under the receiver-operating characteristics curve for prediction of vacuum extraction failure was 0.67 (95% CI, 0.57-0.77) and the optimal AoP cut-off was 145.5°. Above this value, the rate of vacuum extraction failure fell below 5%. CONCLUSION: AoP is a predictive factor of failed vacuum extraction, especially among nulliparous women whose risk of failure is high. AoP measurement may help in choosing between forceps and vacuum extraction. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Non-invasive prenatal testing for trisomy 21 based on analysis of cell-free fetal DNA circulating in the maternal plasma.

OBJECTIVE: By-the-book implementation of non-invasive prenatal test and clinical validation for trisomy 21. STUDY DESIGN: Publicly funded prospective study of 225 cases. Women at risk for trisomy 21 > 1/250 based on combined ultrasound and serum markers during first or second trimester were eligible following an informed consent. The technique was established from the available literature and performed on 10 mL of venous blood collected prior to chorionic villus sampling or amniocentesis. Investigators were blinded to the fetal karyotype. Results were expressed in Z-scores of the percentage of each chromosome. RESULTS: Among 976 eligible cases, 225 were processed: 8 were used for pretesting phase and 23 to build a reference set. One hundred thirty six euploid cases and 47 with trisomy 21 were then run randomly. Eleven cases yielded no result (4.8%). Z-scores were above 3 (7.58+/-2.41) for chromosome 21 in all 47 trisomies and in none of the euploid cases (0.11+/-1.0). Z-scores were within normal range for the other chromosomes in both groups. Using a cut-off of 3, sensitivity and specificity were of 100% 95% CI [94.1, 100] and 100% 95% CI [98, 100], respectively. CONCLUSION: Non-invasive prenatal test for trisomy 21 is a robust strategy that can be translated from seminal publications. Publicly funded studies should refine its indications and cost-effectiveness in prenatal screening and diagnosis. © 2015 John Wiley & Sons, Ltd.

[Elastography of cervix to predict delay from induction to delivery]. / Élastographie du col utérin : prédiction du délai d'accouchement lors d'un déclenchement par prostaglandines.

OBJECTIVE: Induction of labor for medical indications has become a routine practice. To date, the Bishop score remains as the standard method to predict the duration of induced labor. Elastography is an objective method of assessing the relative consistency of tissues. Therefore, we sought to assess strain elastography of cervix to predict delay from induction to delivery in pregnant women with a low Bishop score. PATIENTS AND METHODS: Ultrasound elastography was immediately performed before induction of labor for medical indications among patients with a singleton pregnancy at>36 weeks of gestation and a Bishop score<6. Patients received 50 µg of misoprostol intravaginally, repeated 6 hours later if regular painful uterine contractions had not started. A second ultrasound elastography was also performed 6 hours after starting the induction before the second dose of misoprostol if regular painful uterine contractions had not started. At each examination, a color map from blue (hardest tissue) to red (softest tissue) was produced. The cervical elastography was considered as positive if at least one part of its anterior wall was red. We assessed the predictive value of elastography on vaginal delivery within 24 hours. Patients delivering by cesarean section were excluded from this study. RESULTS: Elastography was initially performed in 48 patients. Twelve patients delivering by cesarean section after induction of labor were excluded, leading to 36 patients evaluated in this study. Among these 36 patients with elastography performed before induction of labor, 20 had a second elastography before the second dose of misoprostol. Sensibility, specificity, positive predictive value (PPV) and negative predictive value (NPV) of elastography performed before induction of labor on vaginal delivery within 24 hours were 40%, 27.3%, 55.6%, and 16.7%, respectively. Sensibility, specificity, PPV and NPV of elastography performed before the second dose of misoprostol were 64.3%, 16.7%, 64.3% and 16.7%, respectively. Among the 8 patients with red color occurring on the second cervical color map, sensibility, specificity, PPV and NPV were 83.3%, 0%, 62.5%, and 0%. DISCUSSION AND CONCLUSION: Qualitative cervical elastography is a poor predictor for delay from induction to delivery in pregnant women with a low Bishop score.

Birth of a boy with isolated short stature after prenatal diagnosis of a Xp22.3 nullosomy due to an inherited t(X;15) (p22.3;p10) translocation.

KEY CLINICAL MESSAGE: Translocations between X and acrocentric chromosomes are rare. We report on the inheritance of a familial t(X;15)(p22.3;p10) translocation in a fetus referred for short long bones. Cytogenetic analysis revealed an unbalanced translocation combined with a three-gene nullosomy. After genetic counseling, a prognosis was established and a healthy boy was delivered.

[Standardization of the gynecological emergency ultrasound examination]. / Standardisation de l'échographie aux urgences gynécologiques.

Standardization of the gynecological emergency ultrasound examination could allow more accurate evaluation in gynecologic or general emergency unit. A systematic set of images, "Standardized Acute Female Echography" (SAFE), was defined. In practice, four pictures are realized whatever presenting complaint (set "A"). These pictures describe the normal anatomy and allow verifying the quality of ultrasonography realization. The picture A1 is obtained by abdominal probe and investigates the Morison's pouch. The pictures A2, A3 and A4 are obtained by transvaginal probe and correspond respectively to the mid-sagittal uterus view, the right ovary and the left ovary. For each of these pictures, some quality criteria were defined allowing a control of ultrasound examination. When abnormality is detected, others pictures (set "B)" are required to describe it. These pictures are called B1 in case of intra-uterine abnormality and B2 in case of adnexal abnormality. This standardization of pelvic ultrasonography could allow a quality control and a delegation of the ultrasound examination by training physicians or diagnostic medical sonographers without repetition of the examination. SAFE could be a reference in the field of gynecological emergencies imaging picture by improving diagnostic and therapeutic management.

Prenatal BACs-on-Beads™ : a new technology for rapid detection of aneuploidies and microdeletions in prenatal diagnosis.

OBJECTIVE: Molecular cytogenetic techniques on uncultured prenatal samples are the sole tests applied in some countries in cases with advanced maternal age (AMA) or increased risk after prenatal screening. Moreover, there is a trend to perform invasive prenatal diagnosis (PD) during the first trimester before ultrasound manifestations, so new rapid and reliable assays are necessary to investigate microdeletions not detectable with the conventional karyotype. We report the validation study of the prenatal bacterial artificial chromosomes-on-Beads™ (BoBs™ ; CE-IVD), a bead-based multiplex assay detecting chromosomes 13, 18, 21, X/Y aneuploidies and nine microdeletion regions having an overall detection rate of 1/1700. METHOD: We retrospectively studied 408 selected samples and prospectively tested 212 consecutive samples ascertained for conventional karyotyping. RESULTS: We did not find false-positive results. Triploidies were not detected. Maternal cell contamination of male samples up to 90% was unmasked inspecting gonosome profiles. Mosaic conditions at 20 to 30% were revealed. Failures were due to low amount of DNA. CONCLUSION: Prenatal BoBs™ is a robust technology for the investigation of fetuses with normal karyotype with or without sonographic abnormalities. Running in parallel with the karyotype analysis, it can be proposed instead of rapid FISH or QF-PCR providing rapid results on common aneuploidies and additional information regarding the microdeletion syndromes.

Severe life-threatening hemoperitoneum from posttraumatic avulsion of a pedunculated uterine leiomyoma.

Uterine leiomyomas are common tumors in women, and most of their complications are well known. Rupture of a uterine leiomyoma is an unusual source of severe hemoperitoneum. The cause seems to be spontaneous rupture of a leiomyoma vessel or is secondary to abdominal trauma. Herein, we describe the case of a 46-year-old woman who had a history of uterine myomas and came to the emergency department with acute abdominal pain after she fell while jogging. The patient's hemodynamic parameters were stable. An ultrasound examination and computed tomography scan showed multiple uterine myomas and free fluid in the peritoneum without signs of splenic rupture. Laparoscopy was performed, which revealed active bleeding from the base of a pedunculated myoma. The patient required transfusion of 2 units of packed red blood cells, and a subtotal hysterectomy via laparotomy was performed, with an uneventful postoperative course. Because surgical management is needed in an emergency, physicians should be aware of this rare but severe complication in patients with known uterine myomas.

[Hair micrograft technique for eyebrow reconstruction]. / Reconstruction du sourcil par microgreffe capillaire.

SUBJECT: The eyebrow reconstruction should restore an eyebrow with a natural shape and with matching hair direction. METHOD: We describe the micrograft hair technique for eyebrow reconstruction, using either hair from the opposite eyebrow or hair from the scalp. We illustrate our technique with three clinical cases: a traumatic eyebrow injury, a burn scar and a progressive hair loss. DISCUSSION: We insist on the advantages of this technique which is simple, "taylor-made" and which allows to choose the hair direction according to the eyebrow topography. The micrograft hair technique has many advantages in comparison with scalp strip grafting or hair-bearing island scalp flap techniques. CONCLUSION: The eyebrow reconstruction using micrograft hair technique is a simple effective technique offering a better cosmetic result than usual techniques by achieving a natural hair direction and density.

Human hair shape is programmed from the bulb.

BACKGROUND: Few biological data on curly hair follicles have been reported in the literature. OBJECTIVES: To investigate the growth and morphology of curly hair follicles. METHODS: Follicles were dissected from scalp skin samples from African, Guyanese and caucasian volunteers and were observed macroscopically, in culture in William's E medium, and by immunohistochemistry. RESULTS: Macroscopic study of scalp biopsies obtained from African volunteers showed that the dermal implantation of follicles was curved with a retrocurvature at the level of the bulb, as opposed to a straight shape in caucasian follicles. The bulb itself was bent, in the shape of a golf club, while both the outer root sheath (ORS) and the connective tissue sheath were dissymmetrical along the follicle. In vitro growth of curly hair follicles was slightly slower than that of caucasian follicles but, more importantly, the curvature was maintained in the hair shaft produced in vitro. As shown by immunohistochemistry, the proliferative matrix compartment of curly hair follicles was asymmetrical, Ki-67-labelled cells being more numerous on the convex side and extending above the Auber line. On the convex part of the follicle, the ORS was thinner and the differentiation programmes of the inner root sheath and hair shaft were delayed. Furthermore, some ORS cells expressed alpha-smooth muscle actin protein on the concave side of the curvature, reflecting a mechanical stress. CONCLUSIONS: Hair curliness is programmed from the bulb and is linked to asymmetry in differentiation programmes.

[Indications for micrograft hair transplantation]. / Microgreffes de cheveux et de poils: leurs multiples indications.

Advances in treatment of androgenetic alopecia have led to the development of novel medical or surgical therapies adapted to the severity of hair loss and balding. Follicular units or tiny micro-graft hair transplants are a fundamental technical progress. This technique leads to the simple and painless permanent restoration of hair in male and female baldness. It provides the patient with a group of 1 to 3 hairs, emerging from a single orifice. The difference between androgenic receptors of occipital areas and those of other areas explains the permanent nature of the implanted hair growth. The degree of male or female androgenetic alopecia can be determined according to Hamilton's static classification or Ludwig's Classification, or it can be measured and monitored more accurately with Bouhanna's Dynamic Multifactorial Classification. The current indications for micro-graft transplantation are

Multifactorial classification of male and female androgenetic alopecia.

BACKGROUND: Various classifications of male androgenetic alopecia have been described. In fact, all the classification schemes proposed so far are only topographic. A more objective, accurate, and detailed approach to classifying baldness is needed. OBJECTIVE: To propose a dynamic multifactorial classification of certain parameters that can be quantitated and computerized. METHODS: A multifactorial classification has been developed to study parameters such as fixed distances of the face, scalp mobility and thickness, and covering power of hair. This includes density, caliber, shape, length, growth rate, and hair color. RESULTS: Classification proved to be efficient during the fluctuations of different parameters in hormonal and minoxidil treatments. It also helps to determine surgical indications of hair transplant and the stage of maximal baldness. CONCLUSION: This approach will lead to a better evaluation of the evolution of androgenetic alopecia in both sexes, either spontaneously or under treatment.

[Current treatment of androgenetic male and female alopecia (with the exception of hormone treatment)]. / Traitements actuels des alopécies androgénétiques masculines et féminines (traitements hormonaux exceptés).

Various non-hormonal therapies, either prescribed systemically such as certain hair-specific vitamins, or applied via the topical route, such as 2% Minoxidil, permit a normalisation of androgenic hair loss. The trichogenic action of these products should be verified in each individual with a comparative study using a trichogram and a phototrichogram. Any alopecia, be it large or small, may cause aesthetic discomfort. Currently, no medical or cosmetic product can give hope for a discernible and definitive hair regrowth. Only a micrograft reimplantation, hair by hair, produces tangible, aesthetically-denser hair in the bald region.

[High pedicle scalp flaps]. / Les lambeaux de cuir chevelu à charnière haute.

A retrospective study of 207 transposition flaps with a high pedicle of various sizes and locations allows a better understanding of the esthetic effects, the reliability, the complications and the indications of this hair replacement surgery. Four kinds of flaps with a high pedicle have been transposed separately or jointly for an immediate correction of pattern baldness. The long flaps are delayed but the short flaps are transposed in one session without delay.

Topical minoxidil used before and after hair transplantation.

A 2% solution of topical minoxidil was applied on the recipient bald scalp of 16 patients aged 25 to 52 years with Hamilton classifications of androgenetic alopecia from III to VI. Therapy was begun 4 weeks before surgery, was interrupted for 3 weeks, and was started again and continued for 3 months. Four-millimeter donor grafts were inserted into 3.5-mm recipient sites. Follow-up utilizing macrophotography was done for 3 months on 4 grafts near a tattooed area. In 71% of the 64 grafts, partial or total hair is still growing without the shedding that usually occurs 2-4 weeks after transplantation. Topical minoxidil seems to be an adjunct for a better evolution of grafts after hair transplantation surgery.