Management of androgenic alopecia: a systematic review of the literature.

We aimed to determine the efficacy of the various available oral, topical, and procedural treatment options for hair loss in individuals with androgenic alopecia. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of the National Library of Medicine was performed. Overall, 141 unique studies met our inclusion criteria. We demonstrate that many over the counter (e.g. topical minoxidil, supplements, low-level light treatment), prescription (e.g. oral minoxidil, finasteride, dutasteride), and procedural (e.g. platelet-rich plasma, fractionated lasers, hair transplantation) treatments successfully promote hair growth, highlighting the superiority of a multifaceted and individualized approach to management.

A Novel Method of Intraoperative Calculation in Follicular Unit Transplantation: 'The Sequential Strip and FUE Method'.

Hair loss, in particular androgenetic alopecia, has troubled humans since the dawn of history. Treatment options for hair restoration have undergone massive transformation from punch grafting to follicular unit transplantation. Current surgical treatment options in hair restoration fall broadly under two categories, follicular unit transplantation most commonly known as strip method and follicular unit extraction (FUE). The strip method though widely used initially is not so common now due to its fair share of disadvantages ranging from linear donor scar, scar widening to strip overharvesting and wastage of grafts. Follicular unit excision (FUE) was introduced as an alternative method for extraction of grafts to combat the donor linear scar produced by strip method but the disadvantages of FUE include the number of grafts harvested in a single session, moth eaten appearance of donor area caused by over extraction of grafts and harvesting from outside the safe zone. Newer developments like extraction of axillary hair, body hair and pubic hair have been sought to overcome the limitations of number of grafts harvested in a single session of FUE. With more patients now affected by alopecia in their early 20s, there is an ever-increasing demand from the patients for the youthful hairline and hence the focus has shifted towards mega and giga sessions of hair transplantation which pose danger of over extraction of grafts leading to depletion of available donor sites. This article elaborates the combined sequential strip and FUE method along with an intraoperative calculation model to overcome the limitations of over extraction and wastage of grafts. (1) Combination of techniques Strip method with FUE. (2) An intraoperative calculation model that aids in limiting over extraction and wastage of grafts. (3) It is a real time model which can be applied in practice with ease.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Most Influential Publications Regarding Hair Transplantation: A Bibliometric Review.

INTRODUCTION: This bibliometric review aims to assess the impact of significant publications within the field of hair transplantation. Citation counts will serve as a primary influence indicator. METHODS: An exhaustive search was conducted using Clarivate's Web of Science database, yielding 260 publications related to hair transplantation. These were evaluated and sorted based on citations, narrowing down to the 50 most highly cited works for analysis. Parameters including citation density, authorship, institutional affiliations, country of origin, year of publication, article topic, and the level of evidence for each publication were obtained. RESULTS: Analyzed publications were cited a total of 1341 times. Authorship analysis revealed that the most significant contributors regarding hair transplantation were Bernstein and Rassman. We also identified the leading institutions affiliated with these works, highlighting the primary academic and research centers driving the field. Geographical analysis exhibited the US' dominance in producing impactful publications. Most publications were also classified within Level IV and Level V according to the Oxford Levels of Evidence system. CONCLUSION: This review provides a comprehensive snapshot of the pivotal publications shaping hair transplantation. Our findings underscore significant contributions within this field and may assist researchers and clinicians in understanding the evolution and the current state of the hair transplantation literature. This bibliometric analysis can serve as a roadmap for those seeking to delve into this rapidly evolving field, facilitating the identification of research gaps and formulating future research directions. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Scoping Review on Complications in Modern Hair Transplantation: More than Just Splitting Hairs.

BACKGROUND: Hair restoration surgery (HRS) is a commonly performed elective procedure but to date lacks a review of the full scope of complications. OBJECTIVES: To provide a comprehensive overview of observed complications associated with follicular unit extraction (FUE) and follicular unit transplantation (FUT). ELIGIBILITY CRITERIA: Randomized control trials, cohort studies, case series, and case reports published in 1985 or later on adults (age>18). Nontraumatic or autoimmune etiologies of alopecia were excluded as procedure indications. SOURCES OF EVIDENCE: PubMed, EMBASE, Cochrane databases (last search December 31, 2022). CHARTING METHODS: Data-charting and extraction were independently performed with two reviewers using Covidence. RESULTS: Forty-three publications were included. Two large series reported the overall complication rate to be 1.2 and 4.7%. Common complications included bleeding requiring intervention (up to 8%), persistent numbness (up to 11%), infection (up to 11% with two reports of Kaposi varicelliform eruptions and one of mucormycosis), effluvium at donor and recipient sites (up to 4.1% and 6.5%, respectively). The most common donor-site complication was hypertrophic scarring/keloid formation after FUT (up to 15.1%). Complications at the recipient site, including crusting (up to 54.8%), frontal edema (up to 50%), and sterile folliculitis (up to 53.3%), tended to be poorly defined with a broad range of incidences. CONCLUSION: Serious complications associated with HRS are rare in the hands of experienced providers. However, comprehensive discussions of risk must be had with prospective patients as any complication in the context of an elective procedure may be significant and psychologically devastating for the individual patient. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Management of Cowlick in Female Hairline Correction Surgery.

PURPOSE: To investigate the results of two grafting methods to manage CLs in the FHL of women. BACKGROUND: The present study was performed to investigate the results of two grafting methods to manage cowlicks (CLs) in the frontal hairline of women. METHODS: Patients were categorized into two groups based on the grafting method: the matching with the original hair direction (MOD) group and the matching with the CL hair direction (MCD) group. Satisfaction ratings were compared between the two groups. RESULTS: Among 80 patients, 77 had a single CL and 3 had a double CL. In the MOD group, 7 of 12 (58.3%) patients underwent a touch-up procedure for density enhancement with an average of 123 follicular units; the average patient and physician satisfaction ratings were 4.84 and 4.60, respectively. In the MCD group, 7 of 68 (10.3%) patients underwent a touch-up procedure for density enhancement around the CL; the average patient and physician satisfaction ratings were 4.64 and 4.50, respectively. CONCLUSION: In female hairline correction surgery, the surgeon must choose between MOD and MCD by considering the location, shape, and pattern of the CL; the facial shape; and the patient's preference. Delicate graft placement is required to obtain natural-looking results. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors. www.springer.com/00266 .

Recipient Site Necrosis After Follicular Unit Excision Technique For Hair Transplantation: Evaluation of 18 Patients.

BACKGROUND: Hair transplantation is a widely performed cosmetic procedure for hair restoration. While generally safe, it carries the risk of complications, including recipient site necrosis (RSN). RSN is a rare but serious complication. This study aims to conduct a detailed analysis of 18 patients who had necrosis in the recipient area after hair transplantation. METHODS: A retrospective review of medical records was conducted on 18 consulted patients who developed RSN following hair transplantation between 2017 and 2023. Data collected included patient demographics, medical history, surgical details, treatment modalities, and outcomes. Treatment involved surgical intervention (debridement), and conservative measures (wound care) in all cases. RESULTS: The mean age of patients was 36.06 years (range: 22-48). The most common risk factors identified were smoking 66.7% (n = 10), hypertension 20% (n = 3), and diabetes mellitus 13.3% (n = 2). All patients (n = 18) underwent single-session hair transplantation using the follicular unit excision technique, and an average of 3899.44 ± 93.76 follicular units were transplanted. Outcomes such as scarring and graft failure occurred in all patients. CONCLUSION: The presented study is the largest complication series in the literature. RSN is a rare but significant complication of hair transplantation. Identifying and managing risk factors, such as smoking, diabetes and hypertension, is crucial for prevention. Early recognition and prompt treatment are essential for optimal outcomes. While conservative management is often successful, surgical intervention may be necessary in severe cases. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Risk Factors and Hazards of Recipient-Area Perifollicular Erythema After Hair Transplantation: A Multicenter Retrospective Cohort Study.

BACKGROUND: Recipient-area perifollicular erythema (RPE) may delay graft growth after hair transplantation. However, there is currently a lack of observational clinical studies of RPE. OBJECTIVE: To study the clinical features and risk factors associated with RPE while analyzing its correlation with graft growth. METHODS: We conducted a multicenter retrospective cohort study between June 2020 and January 2023. RESULTS: A total of 1090 participants were included, 178 (16.33%) showed mild RPE, 56 (5.14%) showed moderate RPE, and 10 (0.92%) showed severe RPE. Patients with RPE had severe hair shaft shedding (P < 0.001) and a lower survival rate (P < 0.001) of grafts. Logistic regression analysis showed that folliculitis is a significant risk factor for mild RPE (OR 6.061, 95% CI 3.343-10.991, P < 0.001) and moderate RPE (OR 3.397, 95% CI 1.299-8.882, P = 0.013). Besides, untimely first postoperative hair washing was associated with the development of moderate RPE (OR 0.724, 95% CI 0.553-0.947, P = 0.018) and severe RPE (OR 1.553, 95% CI 1.156-2.086, P = 0.003). CONCLUSION: RPE is a postoperative complication closely related to high hair shaft shedding proportion and low graft survival rate. Both postoperative folliculitis and untimely first postoperative hair washing may induce the occurrence of RPE. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An Analysis of Risk Factors of Recipient Site Temporary Effluvium After Follicular Unit Excision: A Single-Center Retrospective Study.

BACKGROUND: Temporary hair loss at the recipient site after hair restoration surgery is called shock loss (SL). This study analyzed the risk factors for SL among patients who received follicular unit excision. MATERIALS AND METHODS: This study included 621 patients (554 males and 67 females). Twenty-three patients had SL (9 males and 14 females with a mean age of 40.8 years). The prevalence of SL was analyzed in relation to sex, age, graft follicular units, cause of alopecia, diabetes mellitus, smoking, drinking alcohol, and local anesthesia agent. RESULTS: Sex was identified as a risk factor for SL (odds ratio [OR]: 30.18; 95% confidence interval [CI] 9.43-96.55; p<0.001). Among female patients, age was identified as a risk factor for SL (OR:1.07; 95% CI 1.00-1.15; p=0.039). Over 40 years, the female pattern hair loss group had a significantly higher risk for SL than a female cosmetic group younger than 39 years. CONCLUSION: Sex was the only risk factor found for SL in this study. In addition, age was identified as a risk factor for SL among female patients. We believe our results provide information and risk factors for SL, not only for hair transplant surgeons, but also patients who will receive follicular unit excision. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Randomized control trial to study the efficacy and safety of platelet-rich plasma as intraoperative holding solution in hair restoration surgery: A pilot study.

Background: Hair restoration surgery is a definitive surgical procedure undertaken for androgenetic alopecia (AGA). Platelet-rich plasma (PRP) therapy has gained importance in recent times as a valuable adjunct to therapy in hair restoration. However, the various beneficial effects of PRP as intraoperative holding solution hair restoration surgery remain to be objectively defined. Methods: Twenty cases of AGA were allocated into two groups (PRP and non-PRP). The follicular grafts harvested were stored in platelet-rich plasma/chilled ringers lactate solution depending on subject/control and were implanted in receding hairline using hair implanters. Patients were reviewed at the end of 2 weeks, 4 weeks, 8 weeks, 3 months, and 6 months using clinical and folliculoscopic images. The analysis was performed using SPSS version 20.0. Results: Follicular growth as assessed using the percentage of grafts in actively growing phase posttransplant showed faster recovery from 'shock effluvium' in the PRP group when compared with the non-PRP group from Week 4, through Week 8 and 3 months with the 'lead' increases of percentage growth difference being statistically significant(P = 0.02) between the two groups. At the end of 6 months, 100% of patients recorded a hair shaft length of >10 mm in the PRP group, whereas only 20% achieved >10 mm length. The difference in hair densities between PRP and the non-PRP group from 4 weeks up to 6 months in the non PRP group remained significant (P < 0.05). Conclusion: Intraoperative PRP as a holding solution improves outcome in hair restoration surgery by a significant improvement in the mean density of the implanted follicular unit grafts at 6 months.

The pros and cons of follicular unit extraction (FUE) versus elliptical donor harvesting (FUT).

Hair transplantation has evolved as a practice since the 1960's with advances in technology and surgical technique. With various surgical techniques in existence, patients and practitioners have an abundance of options to curate the best results for the patient. However, with many options come various benefits and consequences that must be examined on a patient-by-patient basis. This review article sought to examine the various surgical modalities of hair transplantation, to outline the pros and cons of various techniques, and to help outline considerations when choosing a given surgical technique.

Treatment of scarring alopecia in children using follicular unit hair transplantation.

BACKGROUND: Scarring alopecia can significantly affect children emotionally. Follicular unit excision (FUE) and follicular unit transplantation (FUT) have been applied for scar treatment. OBJECTIVE: This study aimed to evaluate the safety and feasibility of follicular unit hair transplantation in treating scarring alopecia in children. PATIENTS AND METHODS: A total of nine children (seven males and two females) with cicatricial alopecia, ranging in age from 5 years, 2 months to 12 years, 10 months were included in this study. Scar formation time ranged from 7 months to 5 years. Sites were vertex (2), eyebrow (3), frontal hairline (3), and temporal regions (2). RESULTS: Nine children in this group were followed up for 6-34 months with the following treatment options: FUE (5 cases), FUT (3 cases), and FUT combined with FUE (1 case). No significant complications were observed during the treatment. The transplanted hair grew well, the direction and shape were satisfactory, and the survival rate was >90%. CONCLUSION: For children with burn trauma and cicatricial alopecia after surgery, hair transplantation can significantly improve their appearance with low surgical risk and high patient satisfaction rate.

New Donor Excision Design for Better Hair Alignment in Hair Restoration Surgery.

BACKGROUND: The linear scar and misalignment of hair follicles are disadvantages of the follicular unit transplantation (FUT) or strip technique. The most common misalignment is at the end of the strip. Although most surgeons try to match hair direction to achieve optimal hair alignment, their attempts are often unsuccessful. OBJECTIVES: We aimed to assess strip designs to improve hair alignment during hair transplantation. METHODS: We conducted a retrospective study of 157 patients who underwent hair transplantation with either the commonly used elliptical incision or our novel triangular flag-shaped designed incision on the donor strip tip. Two blind evaluators assessed the outcome of hair alignment using a 5-point visual analog scale. RESULTS: In total, 303 wounds on 157 patients were assessed. Overall, our triangular flag-shaped design (TFD) achieved better hair alignment than the common elliptical design (CED) (p=0.01). Patients with hair direction straight on the upper wound edge and hair direction inward on the lower wound edge showed improved outcomes with TFD, whereas patients with hair direction inward on both upper and lower wound edges showed better outcomes with CED. CONCLUSIONS: The TFD tip of donor strips achieved proper hair alignment for most hair transplant patients. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Hair transplantation-sustainably planned and performed by the physician]. / Haartransplantation ­ nachhaltige ärztliche Planung und Durchführung.

BACKGROUND AND OBJECTIVES: Microsurgical autologous hair transplantation, when performed as follicular unit transplantation, may permanently and naturally improve advanced androgenetic alopecia in men and women and also non-active scarring alopecias. MATERIALS, METHODS AND RESULTS: Sufficient donor hair and realistic patient expectations as well as an individual surgical planning of the hair distribution are crucial prerequisites for a sustainable hair restoration. They should be determined and evaluated during a personal pre-examination and consultation with the hair surgeon. Natural results can be achieved by transplanting up to several thousands of follicular units with high densities into small micro-slits. This technique also allows for increasing the hair density without injuring surrounding original pre-existing hairs. In progressive, early or advanced androgenetic alopecia, additional medical therapy is highly recommended to stabilize the condition. Otherwise, depending on supply and demand of donor hair, only a partial hair restoration can be achieved with a satisfying density. CONCLUSIONS: Since hair transplantation requires a precise sequence of surgical steps and careful handling of the tiny grafts, the skills and experience of the hair surgeon and his or her team are crucial. The medical risks of an assembly-line way of performing this surgery by non-licensed, non-physician staff, as reported from national clinics and medical tourism, should not be underestimated. The German Association of Hair Surgeons and the International Society of Hair Restoration Surgery offer patient information, as well as continuous medical education and guidelines for interested physicians to ensure the highest quality standard of care.

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.

Successful follicular unit extraction in a case of inactive, recalcitrant alopecia barbae.

Alopecia areata (AA) is a non-scarring autoimmune type of alopecia. Hair transplantation in AA is not practiced as the implanted follicular grafts might be destroyed due to underlying autoimmune pathology. A biopsy proven 28 year old male patient of AA presented to us with an 8-year history of a hairless patch over the beard area. He underwent many treatments by other dermatologist with oral, topical, and intralesional immunosuppressants, which curtailed his disease progression but failed to re-grow hair. Biopsy during his visit revealed absence of inflammatory infiltrates and empty hair tracts replaced by fibrotic tracts. Follicular unit extraction (FUE) was done successfully after counseling the patient about the controversial role of hair transplant surgery in AA. Hair growth was achieved within 6 months with no recurrence during 1-year follow up. FUE can be opted for long-standing and clinically stable cases of AA; histopathology and dermoscopy being the guiding lights in determining the disease inactivity.

Hair Transplant with Strip Harvest: Indications, Contraindications, and Technique.

The evolutionary process of modern hair transplantation began with the plug era and, transitioning through a period of minigrafting and micrografting, finally led to follicular unit transplantation (FUT). Apart from the expansion of donor:recipient ratio, this technique produces an excellent esthetic result, indistinguishable from the natural hair. The merit of strip harvest lies in the maximum amount of follicular unit harvest, minimizing the amount of hair follicle transection, and producing a single scar, irrespective of number of sessions. This article summarizes the prerequisites, indications, contraindications, and technique of strip harvest.

Overview of Follicular Extraction.

Follicular unit extraction (FUE), now named as follicular unit excision, is one of the methods of harvesting hair follicles from the donor area for implanting in the recipient area. The occipital scalp area is the most common donor area, but nonscalp donor areas like beard, chest, and other hairy body parts can be used as donor hair follicle area. The extraction of the hair follicle leaves a tiny circular scar over the donor area. Over the past 20 years, various devices for FUE have been developed, starting from manual, simple motorized to highly advanced motors with rotation, oscillation, and vibration. Similarly, different types of punch are used: dull, sharp, ultrasharp, serrated, hybrid and specially designed punch blade for long hair follicles harvesting in various diameters from 0.7 mm to 1.1 mm. The follicles can be harvested either by manual method or by motorized method.

Optimal Hair Transplant Recipient Site Slit Design: Minimizing Vascular Damage.

An often overlooked aspect of hair transplantation is the art of recipient site design and slit creation. There is also a lack of consensus on which technique provides the optimum coverage while minimizing vascular damage. This paper aims to provide logical arguments to determine the optimal instrument and method of slit creation, in order to ensure maximum density, optimal survival, minimal pop-out, and minimal damage to scalp vascularity. The use of semiconical blades reduces the damage to the dermis and vascular plexus as compared with rectangular blades and needles, as the depth of penetration required is lower. The use of acute angle reduces the depth of penetration for the same length of slit and decreases damage to deep plexus. Coronal slits produce less vascular damage than that of sagittal slits with the same size blades. We believe that these recommendations provide the optimum volume slits while causing minimal vascular damage.

Beard and Moustache Reconstruction.

Beard and moustache reconstruction has gained more popularity and acceptance over the last decade. The procedure is done for the correction of facial areas with hair density deficit and also for the cosmetic enhancement of pre-existing facial hair. The surgical technique includes the harvesting of grafts from the scalp by the follicular unit excision (FUE) or follicular unit transplantation (FUT) technique and then placing them in either premade slits or by stick and place method. The advancement and refinement of procedure over the years has aided in achieving the optimal aesthetic results, with minimal side effects.

Investigation of optimum transplant and extraction density based on the data from the donor area of Chinese androgenetic alopecia patients: a multicenter, retrospective study.

The rise in the incidence of androgenetic alopecia (AGA) in China has increased the inclination toward hair transplantation. To calculate the optimum density of hair follicles needed covering both the hairless area and the safe donor area (SDA), 119 male patients with AGA were recruited into this multicenter investigation. We evaluated the mean diameter and the number of hair follicles (HFs) and follicular units (FUs) in the SDA of AGA. The mean density of HFs was 137.45 ± 30.11 hair/cm2 and the FUs was 76.82 ± 12.09 FUs/cm2. The mean diameter of the hair was 0.97 ± 0.01 mm in the SDA. We obtained the decisive factors in the restoration of the scalp by building a geometric model and summarizing it in a new formula. This study showed that the length and direction of the hair play a vital role in restoring the bald area with hair transplantation. The density of 55.00 ± 10.00 hair/cm2 (30.00 ± 5.00 FUs/cm2) for the transplanted area and no less than 106.88 hair/cm2 (60.00 FUs/cm2) for SDA is regarded as an optimum parameter for hair transplantation of AGA.