Hair Restoration and Hair Transplantation

Hair Restoration and Hair Transplantation

Hair Care, Hair Mesotherapy, Hair Physiology, FUE Method Hair Transplantation

Although it varies in areas of the body, the scalp is an organ consisting of terminal hair follicles containing color (pigment).

The scalp on the skull is called scalp and is an abbreviation consisting of the first letters of 5 different words in English. ( skin , connective tissue, a poneurotic tissue (galea aponeurotica; connective tissue that forms a bridge between the muscles in the forehead and nape area), loose areolar tissue (loose connective tissue; allows the scalp to slide on the bone), periosteum (or pericranium). ).

The hair strand consists of the root or hair bulb embedded in the skin and the free hair shaft. There are sweat and sebaceous glands in the root part, and these produce the oil and sweat needed to prevent the skin from drying out. There are muscles called arrector pili between the skin and the hair follicle, and these contract when the autonomic nervous system activity (cold, heat, excitement, etc.) causes the hair strand to become erect.

The hair covering the skin on the skull, along with the beard and mustache area, is the only structure that is tried to be reproduced, unlike other hair-containing areas on the body. Three basic periods are distinguished in the physiological growth and development of hair. This fundamental period is actually similar to the growth, development and death process of any cell. Each hair follicle goes through this process at certain intervals, eventually sheds the hair inside and enters the hair growth cycle again to grow new hair. Since this three-period process occurs in different periods for each hair follicle, no thinning is observed in healthy hair and a normal scalp continues its way with an average of 80 hair follicles falling out per day.

Image Note: Classification made by Norwood in 1975.

The anagen phase is the main growth and cell proliferation phase of the hair. It takes approximately 3-5 years and varies between races. For example, in Asians, it can last up to 7 years and at the end of this period, the hair size can reach 1 meter. Likewise, it is known that hair growth is faster at night because the anagen phase is more active at night.

Telogen phase; It is an intermediate phase of approximately 10 days in which the hair gradually weakens and becomes ready to fall out.

Catagen phase; It covers a period of silence of approximately 3 months following the hair loss. In the next period, the anagen phase, in which cell proliferation increases, is passed again.

Hair loss is a problem that occurs for different reasons that vary from person to person. It may be an underlying factor (infection, rheumatic skin disease, etc.) or it may occur without any reason. Therefore, if the causative agent of hair loss is treated, the hair can be regained.

Hair health can be affected by metabolic and hormonal problems, infections affecting the hair, and rheumatic diseases affecting the skin. Therefore, hair loss that starts recently and suddenly accelerates and is especially concentrated in certain areas should be investigated in terms of these clinical pictures.

The most common cause of hair loss in both genders, especially in men, is androgenic alopecia.

Hair follicles on the scalp contain receptors for testosterone. Testosterone is an androgen type male hormone and is secreted from the adrenal gland in women. Testosterone and its metabolite dehydrotestosterone cause thinning and shrinkage of hair follicles. Why does that happen? The nape area behind the ear is an area that is not affected much in this sense. Androgenic alopecia can start with the forehead and temples in men and progress to the vertex at the back. Sometimes vertex type hair loss may occur together and a hairline bridge may remain in between. Since hair loss and baldness follow a certain pattern in the male gender, various classifications have been made to include men, and the most frequently used one is the one first described by Hamilton in 300 men and then revised by Norwood in 1975 with the evaluation of 1000 men. classification [3,4].

Although medical treatments (medical treatment approaches such as regional ones such as minoxidil or testosterone antagonists that act by passing into the bloodstream such as finasteride) can be tried, the definitive treatment of androgenic alopecia is hair transplantation surgery. Although the results vary from person to person and depending on the quality of the transplantation, more than 80% of the hair follicles transplanted by an experienced team are expected to be retained.

In androgenic alopecia, it starts from the temples in men and spreads towards the top of the head (vertex), while a more scattered hair loss is expected in women. It is associated with testosterone hormone activity in the body. One of the target organs of testosterone is the hair follicles in the skull. It is a form of hair loss that may have a familial predisposition.

Drug treatment of androgenic alopecia includes drugs such as finasteride, which reduces the activity of testosterone hormone, and minoxidil, whose mechanism of action is not fully known. The effectiveness of these medications varies from person to person. Minoxidil is a more commonly used drug and is used morning and evening, and 2% spray forms are preferred for women and 5% for men. Finasteride can cause sexual dysfunction (mostly reversible problems such as impotence, ejaculation problems) and therefore should be used under the supervision of a doctor. Dudasteride, the more effective and new form of this drug, is effective on both types of receptors that may be the source of hair loss. Ketoconazole is a fungicide, and its shampoo form has been shown to reduce dandruff and stop hair loss. The mechanism of action is not fully clear. PRP (platelet-rich plasma) is the slightly cloudy part obtained by separating the person's own blood. This part, which contains various growth factors, is precipitated by centrifuging the blood in special glass tubes or kits and is taken into a syringe and injected into the area to be applied. Its effectiveness in androgenic alopecia is controversial and there are no studies with sufficient clinical evidence. However, various centers state that PRP injection sessions will be beneficial in increasing the number of surviving hair follicles, especially for hair transplant candidates, in order to prepare the recipient area before application. Although botulinum toxin-A is used in many areas, it is one of the preparations that have been clinically tested for hair loss in recent years. Freund and Schwartz published the preliminary results of their open-ended study in 2010(1) and stated that botulinum toxin-A application could reduce hair loss and stimulate alopecia in some men. While the formation of dehydrotestosterone from testosterone, which is responsible for hair loss, occurs more in a bloodless and therefore oxygen-free environment, in the well-blooded area, testosterone converts more into the hormone called estradiol and therefore hair loss may decrease. Botulinum toxin-A is a substance that potentially increases tissue blood flow in the long term (2).

Apart from medication, the most basic treatment for androgenic alopecia is surgery called hair transplantation. Yes. Hair transplantation is a surgery. This is one of the surgeries that should be emphasized and given serious importance, just like all other long and tiring surgeries of plastic surgery. The only branch competent in hair transplantation surgery is plastic surgery.

Hair loss may be reversible when there is an underlying factor. Telogen effluvium is this type of hair loss and is reversible.

Telogen effluvium, which is the second most common type of hair loss in women after androgenic alopecia, actually includes physiological hair loss in newborns and hair loss that can be seen during pregnancy and improves with the growth of new hair. Apart from this, it has been observed that telogen effluvium can occur in cases of goiter (under- or over-activity of the thyroid gland), anemia, malnutrition, low-protein nutrition, heavy diet and excessive stress. Treatment of these factors with medications and nutritional supplements will mostly enable hair to be regained. Get information about this treatment from a plastic surgeon.

Regional hair loss may occur as a result of fungal infection or rheumatic diseases reflected on the skin. This hair loss, called Alopecia areata, stops with nutritional supplements or treatment for the cause, but hair regain is not expected.

Alopecia areata, which is a type of hair loss that starts in a certain area of ​​the hair and spreads in a short time and causes shedding in a certain area after a few weeks, can be stopped by treating the underlying factor, but hair loss in the area is not expected. I have had patients who achieved very good results with platelet-rich plasma (PRP) in these patients. However, this treatment is still in the experimental phase and may not yield positive results in every patient. PRP treatment involves taking the person's own blood, separating it with special systems, then separating the part rich in platelet cells and administering it to the diseased area on the person's scalp. Hair mesotherapy can also be effective in the treatment of alpopecia areata. Hair transplant surgery can be tried in people for whom no medical treatment is effective. However, before this, it must be confirmed that the underlying disease has completely regressed (remission).

Traction alopecia occurs due to the deterioration of blood circulation in the ground as a result of constant excessive tension being applied to the hair. Hair loss may be permanent once settled.

Traction alopecia can be caused by a variety of reasons, from hairpins used in children pulling the hair too much and disrupting blood circulation, to the person suffering from hair pulling disease. In this case, constant disruption of blood circulation causes developmental regression in the hair follicle in the region and causes the hair follicle to become thinner and fall out over time. Although the previously mentioned forms of medical treatment can be tried after traction alopecia occurs, the main treatment is hair transplantation. Unlike androgenic alopecia, the transplanted hair may fall out again if the patient applies tension again. Therefore, it should be tried in suitable patients. For the health of their hair, please do not tie your children's hair too tightly with pins.

There may be congenital deficiencies in certain areas of the scalp. These deficiencies can vary from full-thickness missing skin (aplasia cutis congenita) to congenital alopecia, where only hair is missing.

Congenital partial or complete absence of hair is a not uncommon condition. This condition can be seen with various layers of the skin. In this case, depending on the extent of the deficiency detected, the balding area can be removed at a certain age and the scalp can be brought face to face, or hair transplantation can be applied to the area at a later age. In the anomaly called aplasia cutis, there are usually congenital deficiencies in the skin and may require repair.

One of the most serious problems that cause hairlessness is actually deep burns. Burns leave very serious scars and deformed skin. Sometimes it may be necessary to put skin patches. Hair does not grow in the burned area and is known as cicatricial (scar-related) alopecia.

Any element that creates scars on the scalp actually prevents hair growth in that area. This condition is called cicatricial alopecia. This condition, which can have many metabolic, infectious (bacteria or fungal) or traumatic causes, can be treated with hair transplantation. One of the types of cicatricial alopecia, the cause of which is unknown, is the condition described by Brocq in which hair grows in clumps. Between these clumps, there is hairless and poorly nourished skin, and hair growth is not expected.

In fact, contrary to popular belief, the targeted result should not be hair growth, but healthy hair. Hair health is an issue that requires education in society. Everyone should care for their hair by knowing more or less the structure of their hair, and every patient with the beginning of hair loss should be examined by a physician. It should not be forgotten that hair loss can be caused by many preventable reasons when caught early.

Among the medical treatments applied for hair health, there are results showing that mesotherapy is especially useful in stopping hair loss, balancing the dryness of the hair and increasing the diameter of the hair. It is also used to increase the blood supply to the recipient bed before hair transplantation.

Hair mesotherapy, in parallel with other mesotherapy derivatives, includes initial sessions to increase regional blood circulation and then treatments directed directly to the target, that is, the hair follicle. Although many drug cocktails can be prepared, today they are sold more practically as commercial products. The hair growth effect of mesotherapy is to stimulate the hair follicles entering the telogen phase and their transition to the anagen phase, but the effects are reversible when treatment is interrupted for a long time. The same applies to platelet-rich plasma (PRP) treatment.

Another practice that has become popular recently is to perform 8-10 passes of scanning on the scalp with needle rollers called microneedling.

There are publications showing that when this device is used together with PRP and 5% minoxidil, it provides a significant increase in the number and diameter of hair follicles in the trichogram after 3-4 sessions and that the amount of palpable hair removed in the hair pull test also shows a significant decrease (5, 6). However, I have not observed any studies on the long-term durability of these effects.

When medical treatments for hair restoration do not work, two types of surgery within the scope of aesthetic plastic surgery come into play as a solution. These are tissue expander application and hair transplantation surgeries. These surgeries can also be performed on patients who we think will not get results from medical treatments.

The use of tissue expander balloons in plastic surgery aims to replace unhealthy skin, especially on the basis of a healed burn, with healthy skin with good blood flow. Again, after breast cancer surgery, a permanent silicone prosthesis is placed following the expansion of the existing tissue in order to recreate the breast. Before hair transplantation became widespread in the restoration of balding areas on the scalp, tissue expander implants were mainly used in patients. Tissue expanders provide stretching of the scalp and allow it to spread to the balding area. There is a two-stage surgery process, separated by 2-3 months. In the first one, the tissue expander is entered through an incision in the hairless area and placed in the pocket created under the scalp. Inflation is applied from the inflation chamber 1-2 times a week with physiological saline to the point where the patient's pain begins. Generally, this volume is 10-15% of the total volume. I have patients who inflate to 15-20% more than the maximum volume by the second session. In the second session, the tissue expander is removed through an incision and the scalp is freed. Depending on the amount of area it covers, hairless skin is removed and replaced with scalp. Sutures are placed without tension.

The most ideal results for hair transplant surgery are achieved if there is a healthy recipient bed, a sufficient number of healthy hair patches, and the patient does not have a metabolic disease or a smoking habit.

After the first modern hair transplantation technique was described by American physician Norman Orentreich in 1952, hair transplantation was performed on thousands of patients and very successful results were obtained. Two basic techniques are used for hair transplantation. In the first developed follicular unit transplantation (FUT) technique, an extraction of a certain length and width is applied from the scalp on the nape of the neck, which is resistant to shedding. These are prepared under the operating microscope in sections containing a number of hair follicles ranging from single to quadruple. The area where the scalp was removed is closed with stitches. During the preparation of the hair follicles, the recipient area to which they will be transferred must be prepared and channels are opened there so that the hair can grow at the appropriate angle. Afterwards, hair follicles are transplanted to the area to provide a natural hairline. All surgery is performed with regional anesthesia. In this technique, only the area where the hair patch will be removed is shaved, and at the end of the surgery, the hair follicles are sewn face to face, so the part where the hair follicle is removed is not visible to the patient.

The second hair transplantation technique, follicular unit extraction (FUE), is a surgical technique in which, as stated in its name, the hair follicle patches are removed one by one and then transplanted into the opened channels, similar to the FUT technique. Here, circular knives with diameters ranging from 0.7 to 3 mm, called punch, are used. The punches we use are generally 0.7-0.8 mm in diameter.

In this surgical technique, if the area to be transplanted is large, all of the patient's hair must be shaved with a machine. Unshaved FUE technique can be used in patients who will undergo limited transplantation. In this technique, the patient is required to have long hair. For transplantation, the area with hair just above the area where the hair follicle patch will be taken is preserved, and only the area where the patch will be taken is shaved and this is hidden with the preserved hair on top.

Hair transplantation surgery is a long-lasting surgery and part of the surgery continues in the prone position and the rest in the supine position. This long surgery can sometimes be divided into two-day sessions.

It should not be forgotten that hair transplantation is, first of all, a surgery and this surgery should be performed by a team led by an aesthetic plastic surgeon. Hair transplants performed by non-physicians in under-the-counter hair transplantation centers can result in disappointment, leading to widespread loss of the scalp.

Hair transplantation surgery is not a surgery that causes much blood loss. Following regional anesthesia during the surgery, bleeding is limited by applying a special bandage to the head.

If you are using it before hair transplantation surgery, which is one of the long-lasting operations of plastic surgery, such as 5-9 hours, please stop your blood thinners (aspirin, plavix, xarelto, etc.) as of the date warned by your doctor. Likewise, smoking will negatively affect the nutrition of the transplanted hair patches as it disrupts tissue blood supply. Therefore, stop smoking for at least 1 week before and after the surgery.

Regardless of the technique used in hair transplant surgery, you will be given some suggestions for post-operative care. Paying attention to these suggestions can make the surgery results much more satisfactory.

I do not want you to wash your hair for the first 3 days after hair transplant surgery. This is important for the process of adhesion of hair follicles. In some centers, the channels where the hair will be transplanted are narrow and the recipient area may vomit the placed patch. If the hair patches appear to be excessively protruding at the end of the surgery, washing can be postponed until the 4th or 5th day.

The first wash after the hair transplantation surgery is performed by the hair transplantation team after the 3rd day, and you will be explained how and with what materials to care for your hair.

After hair transplantation, you should wash your hair with special lotions and gentle contact for a while. Never use a blow dryer or curling iron after washing. These devices burn hair follicles and cause rapid hair loss.

After hair transplantation, the crusts that have formed in the transplanted areas must be shed by the end of the first week. Inform your doctor if crusting lasts longer than a week. Long crusting time may negatively affect new hair growth. After the crusts fall off, you can take care of your hair as described.

Do not enter areas such as pools, sea and solariums for the first 10-15 days after hair transplantation surgery. Chemical and infectious pollutants in the pool and sea can damage hair follicle patches. If solarium and sunbathing will be used, I recommend special hats.

In the first days of hair transplantation surgery, a special bandage is applied around your face to prevent excessive swelling. Despite this, there may be widespread swelling around the face and especially in the eyelids. Please get advice from your doctor regarding this.

Any blows to the head after hair transplantation surgery will negatively affect your recovery. Therefore, if possible, limit your sports activities to minimize the possibility of possible impacts.

After hair transplantation, the transplanted hair follicle patches go into the telogen and catagen phase for a while. In other words, they fall out and it may take an average of 6-12 months for them to grow again and for the hair diameter to thicken.

Anemia is a common problem in the development of all tissues and is also an important parameter in hair transplantation. Therefore, maneuvers that accelerate surgery time continue to be developed. To minimize the effects of anemia, hair follicle patches are separated and kept on pads impregnated with a special solution at temperatures between 4-10 degrees. After transplantation, the response of the hair follicle patch to anemia is the transition towards the silent, that is, catagen period. In this process, the hair follicle falls out and a new one begins to grow from below. The first hair strands that appear are thin, but they thicken over time. Mesotherapy can also be useful after hair transplantation in order to shorten the duration of this normal catagen response. Therefore, the loss of transplanted hair should not worry you.

Robotic hair transplantation has recently gained a commercial dimension, especially in the USA, with the approvals given by the Food and Drug Administration (FDA).

As robotic surgery has gained popularity in many areas, it has also begun to be used to reduce the energy and time spent in hair transplantation surgeries. Firstly, the cutting head used to provide the hair follicle patches taken with the technology called NeoGraft at a more appropriate angle without being damaged is accurately measured by taking photographs throughout the application. A mechanism that calculates the angle has been installed. This system still requires a surgeon. The robot used in a second system called ARTAS prepares the hair patches to be transplanted with its punch blade, and a surgeon is still needed to remove the hair follicle from the ground. The robot also opens channels in the recipient area for the patches taken, at the appropriate angle, and then the transplantation is performed.

One problem with these technologies is that the punch blades that can be used are much larger in diameter than normal hair transplantation punches. This causes the prepared hair patches to have larger volume.

Undesirable consequences, that is, complications, that may occur after hair transplantation surgery can reach considerable levels.

As in every surgery, the most classic problems that I can say after hair transplantation surgery are wound infection and blood accumulation under the skin. Especially when disinfection and sterilization rules are not adequately followed, serious infections that can be life-threatening can be encountered. Infections that may occur during hair transplant surgery can cause serious skin abscesses in the area, which can also lead to hair loss. There may even be skin loss. For this reason, hair transplantation should only be performed by aesthetic plastic surgeons who are experts in their field. Because when the mentioned problems occur, the only competent branch to solve them is plastic surgery.

Accumulation of blood (hematoma) under the wound line may occur especially in patients who do not stop taking blood thinners, but may also rarely occur in those who do not use any medication. In this last group, a bleeding focus (hematoma) may occur when the circular knife called punch injures a deep vein. This hematoma must be evacuated with regional anesthesia.

Failure to grow hair can be seen more frequently, especially in teams that have not completed the learning curve, have a high rate of damage to the hair follicle when applying hair follicle patches, and place hair follicle patches at inappropriate angles and by opening channels that are narrower than they should be. As I mentioned before, opening a narrow canal causes the hair follicle to be vomited out of the canal. Some of the automatic hair follicle inserters only insert the patch directly by sinking into the scalp, and these problems may occur more frequently.

Unnatural hairlines and angles are caused by improper planning and placing the wrong number of hair follicle patches in the wrong area. Treatment of inappropriate hairline is not easy, especially when it is too forward in the forehead area, and may require surgery.

Resources:

1. Freund BJ, Schwartz M. Treatment of male pattern baldness with botulinum toxin: a pilot study. Plast Reconstr Surg. 2010 Nov;126(5):246e-248e.
2. Temiz G, Yeşiloğlu N, Şirinoğlu H, Akpınar AC, Sarıcı M, Filinte D, Filinte GT, Bozkurt M. Increasing the survival of transverse rectus abdominis musculocutaneous flaps with a Botulinum toxin-A injection: A comparison of surgical and chemical flap delay methods . J Plast Reconstr Aesthet Surg. 2016 Jul;69(7):944-51
3. Hamilton JB. Patterned loss of hair in man: Types and incidence. Ann NY Acad Sci. 1951;53:708–28.
4. Norwood OT. Male pattern baldness: Classification and incidence. South Med J. 1975;68:1359–65.
5. Bao L, Gong L, Guo M, Liu T, Shi A, Zong H, Xu X, Chen H, Gao X, Li Y. Randomized trial of electrodynamic microneedle combined with 5% minoxidil topical solution for the treatment of Chinese male Androgenetic alopecia. . J Cosmet Laser Ther. 2017 Oct 13.
6. Jha AK, Udayan UK, Roy PK, Amar AKJ, Chaudhary RKP. Original article: Plateletrich plasma with microneedling in androgenetic alopecia along with dermoscopic pre and posttreatment evaluation. J Cosmet Dermatol. 2017 Aug 3. doi: 10.1111/jocd.12394. [Epub ahead of print]