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INSIDE Patterned hair loss Medical therapy Hair replacement surgery The future Case study

THE AUTHORS

PROFESSOR RODNEY SINCLAIR professor of dermatology, University of Melbourne and Sinclair Centre for Dermatology Investigative Research, Education and Clinical Trials, East Melbourne, Victoria.

DR MARIO MARZOLA hair transplant surgeon, Sinclair Centre for Dermatology Investigative Research, Education and Clinical Trials, East Melbourne, Hair restoration Victoria. Background

IT is easy to underestimate the Figure 1. impact of hair loss on men and A 25-year-old women (see figure 1). Hair trans- man before, plantation was first performed by and nine Dr Shoji Okuda in Japan just prior months after 2000 follicular to World War II and popularised by unit grafts. Dr Norman Orentreich from the US in the 1960s.1,2 In a series of experi- ments, Orentreich demonstrated the principle of donor dominance that states that the behaviour of transplanted hairs is determined by the characteristics of the donor site rather than the recipient site. Donor hair follicles transplanted from Melbourne pioneered follicular the anterior hair line to improve the In contrast, follicular unit transplan- from balding vertex scalp onto non- unit transplantation.3 This proce- aesthetics of the final result. tation accounts for over 95% of bald skin continue to miniaturise in dure involves excision and primary In 2000 Dr Ray Woods from Syd- transplants in women, whose longer synch with follicles on the vertex closure of a thin, 10cm long strip of ney described a modified technique hair conceals the scar.5 scalp. Donor hair follicles trans- skin from the occipital scalp, micro- that later became known as follicular Significant advances in the medical planted from non-balding occipital dissection of the strip into individual unit extraction.4 This involves har- treatment of male and female pattern scalp onto bald vertex scalp con- follicle units and then implantation vesting donor follicles with a 0.75mm hair loss over the past 15 years have tinue to grow in sync with follicles one-by-one into the bald scalp. This punch biopsy, further microdissection further improved the surgical out- on the occipital scalp. became the dominant procedure for of the punch tissue into individual fol- comes, the longevity of transplanted Copyright © 2017 The principle of donor dominance the next 30 years. Significant refine- licles and then implantation into bald follicles and patient satisfaction with Australian Doctor has formed the basis of therapeutic ments included the trichophytic clo- scalp. The donor site is left to heal by the procedure. All rights reserved. No part of this hair transplantation to treat men sure to improve the donor scar, better wound contraction and secondary Today, men and women with publication may be reproduced, and women with patterned hair understanding of the optimal donor intention. The lack of a linear occipi- advanced androgenetic alopecia distributed, or transmitted in any loss. Orentreich used 4mm punch site, better handling of follicles with tal scalp is attractive to men who have can be managed effectively with a form or by any means without the prior written permission of the grafts from non-bald scalp to fill in improved implantation techniques short hair, and follicular unit extrac- combination of medical therapy and publisher. For permission requests, bald frontal and vertex scalp. to increase graft survival and better tion now accounts for around 60% of hair transplantation surgery. email: [email protected] In the 1980s Dr Richard Shiell understanding of the intricacies of hair transplants in men in Australia. cont’d next page

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Patterned hair loss Epidemiology ANDROGENETIC alopecia Stage 1 affects all men and all women pro- gressively as they age. There is no 80-year-old man or woman who has the same amount of scalp hair that they had when they were 18. The age of onset and rate of pro- gression varies considerably from person to person, while the pattern of hair loss in men (male pattern hair loss) and women (female pat- tern hair loss) are relatively con- No baldness Bitemporal regression Vertex baldness stant. Stage 2 Stage 2 Stage 3 Premature hair loss is defined Stage 1 as hair loss that exceeds normal age-related androgenetic alopecia. Premature hair loss is an indicator of premature ageing and reduced longevity.6 Premature hair loss may also diminish physical attrac- tiveness. Figure 3. Male hair pattern In men, premature balding is grading scale. commonly an unwelcome and stressful event. In women, even normal age-related hair loss is commonly unwelcome and stress- Stage 3 ful. Many women in their 80s and Frontal baldness Full baldness 90s still go to extreme lengths to Stage 4 Stage 5 conceal age-related androgenetic hair loss. To define the prevalence of female pattern hair loss, one of the A B authors developed and validated a clinical grading scale for female pattern hair loss (FPHL) and per- formed a population-based survey (see figure 2). The age-adjusted prevalence of female pattern hair Stage 4 loss (stage 2-5) in the community is 32.2%, 10.5% of whom have moderate to-severe hair loss (stages 3-5).8 In Australia, with a popula- tion of 24 million, this equates to over four million women with mild FPHL and 1.2 million women with advanced FPHL. To define the prevalence among Figure 4a. Dermoscopic images of scalp in different stages Australian males, one of the C of alopecia. authors also developed and vali- a. Normal scalp with 2-4 hairs in most follicular units dated a clinical grading scale for b. Early androgenetic alopecia with mixture of multiple and single hair in follicular units male pattern hair loss (see figure Stage 5 7 c. Advanced androgenetic alopecia with thin and single 3). The age-adjusted prevalence hair in most follicular units of mid-frontal and vertex scalp hair loss (stages 3-5) was 44.9%. The prevalence increased with age. Only 4.1% of men aged 80 or older had no visible hair loss. This equates to about six million bald- ing Australian men.8 Figure 4b. Histology of a hair follicle. Aetiology Twin studies performed in Queensland confirm that prema- Figure 2. Sinclair scale. Figure 4b ture androgenic alopecia has a Stage 1 is normal. Stage 2 shows polygenetic aetiology.9 The first widening of the midline part. Stage gene for androgenetic alopecia 3 correlates with Ludwig stage I. was discovered in the 1990s by Stages 4 and 5 correlate with Ludwig stage II. As Ludwig III is rarely researchers from the University 10 seen in clinical practice it was not of Melbourne. Genetic poly- included in this grading scale. morphism of the androgen recep- tor gene, which is found on the X chromosome, were found to be associated with premature bald- ness in young men. Two further genes, the oestro- gen receptor beta gene and the aro- matase gene, are associated with female pattern hair loss.11 These genes are involved in androgen sig- nalling and metabolism in the hair follicles. Epigenetic silencing of the androgen receptor gene on the occipital scalp protects these fol- licles from the balding process.12

cont’d page 20

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from page 18 Pathogenesis Hair on the scalp grows differently from hair elsewhere on the human Stage 1 Stage 2 Stage 3 body.13 Body hairs arise from sim- 1 ple pilosebaceous units that com- prise one hair follicle, one arrector pili muscle and one sebaceous gland. Scalp hairs are tufted and arise from complex pilo-sebaceous units comprising one primary hair, up to five secondary hairs that bud 2 off the side wall of the primary fol- licle, a single sebaceous gland and a single arrector pili muscle (see figures 4a and 4b). The arrector pili muscle attaches circumferen- tially around the primary follicle and to the side wall of the second- Stage 4 Stage 5 ary follicles. 3 The initial loss in androgenetic alopecia is due to miniaturisation of secondary follicles over the frontal and vertex scalp (see figure 5). Miniaturised follicles produce rapidly cycling miniaturised hairs. 4 This leads to a diffuse reduction in hair density without visible bald- ness. It may present with increased hair shedding and people with long hair may notice a reduction in the diameter of their pony tail. This may precede the appearance 5 of bald scalp by a number of years. Stage 6 Stage 7 Baldness occurs when all the hairs within a complex pilo-seba- ceous unit have miniaturised to the 6 point of invisibility. Baldness over the temples begins as the anterior hair line moves posteriorly. On the vertex scalp, miniaturisation 7 progresses circumferentially to produce an expanding bald patch (see figure 6). On the frontal scalp, Figure 5. In androgenetic alopecia, miniaturisation occurs initially in the secondary follicles. This leads to a reduction in hair density that precedes visible baldness begins at the anterior baldness. Bald scalp becomes visible only when all the hairs within a follicular midline and moves laterally to cre- unit are miniaturised. With miniaturisation, the muscle initially loses attachment ate the so-called Christmas tree to the secondary follicles. When primary follicles eventually miniaturise and lose patterns (see figure 2). muscle attachment, the hair loss becomes irreversible. Figure 6. Stages of alopecia.

Medical therapy

THE goal of medical therapy is to do not improve efficacy, but are dicated in women of childbearing initiation of therapy. Known side 90% of women, but only regrow arrest progression and stimulate associated with more frequent and age. effects of oral minoxidil include hair in around 30% of women.16 partial regrowth. Oral finasteride severe adverse sexual side effects. Minoxidil can be used alone or hypotension, fluid retention, They are contraindicated in men at a dose of 1mg daily will arrest Finasteride has a protective effect in combination with finasteride. tachycardia and hypertrichosis. because of sexual dysfunction. progression in up to 95% of men against future development of Minoxidil increases hair count, These side effects are all dose- Prostaglandin antagonists and and produce partial regrowth in low-grade prostate cancer.15 prolongs anagen duration and related and can be managed by prostanoids such as latanoprost, up to 60%.14 There are no sig- Dutasteride is a more potent increases the linear growth rate dose titration. Hypertrichosis can bimatoprost, setripiprant and ste- nificant drug interactions and the stimulator of hair regrowth than of hair. Minoxidil is available be managed by depilatory creams, moxydine may also increase scalp main toxicity relates to adverse finasteride, but adverse sexual both topically and orally. Known shaving, waxing, topical eflorni- hair density. The role of LED sexual side effects. While gener- side effects are more common. side effects of topical minoxidil thine or hair removal laser. light, low level laser devices, and ally reversible on discontinuation, Finasteride and dutasteride are include irritant and allergic con- Spironolactone and cyproter- serial injection of platelet-rich there are reports of permanent potent teratogens with a long bio- tact dermatitis, hypertrichosis and one acetate are oral antiandro- plasma is still under investiga- sexual dysfunction. Higher doses logical half-life and are contrain- a temporary telogen effluvium on gens that arrest hair loss in over tion.17

Hair replacement surgery

THERE are two main types of sur- usually contain 10-25 hairs. favoured because of the unnatu- gery. The first is hair transplanta- Smaller ‘mini’ grafts contain 2-4 ral doll’s hair look they produce. tion, which is useful for people who hairs. The ‘micrograft’ contains They should never be used to rec- wish to achieve a modest change in 1-2 hairs. The number of grafts reate the anterior hairline. Punch the fullness of their hair. The sec- required varies according to the grafts account for fewer than 1% ond involves scalp reduction pro- severity of the baldness. For deep of hair transplantation operations cedures, which may produce more bitemporal recession, 500 grafts in Australia. radical results.18 may suffice. A vertex bald spot The hair that is transplanted will may require 750 to 1000 grafts. retain the same growth character- Hair transplantation Stage 5 hair loss baldness (see fig- istics that it had in its original site. Hair transplantation involves ure 3) may require 4000 grafts. Therefore, if the donor site remains removing donor hair from the The two operations most com- well-covered with hair, the recipi- hair-bearing occipital scalp and monly performed by hair trans- ent hair will continue to grow in the relocating it to bald or thinning plantation surgeons are follicular same way. If the donor site begins areas over the temples, frontal or unit transplantation and follicular to bald, the same will happen to the vertex scalp. The size and shape of unit extraction. ‘Punch’ grants are recipient site. As the hair on the the grafts varies. occasionally used for the vertex of back and sides of the head continues Round-shaped ‘punch’ grafts Figure 7. Strip harvesting for follicular unit transplantation. the scalp, however, these are rarely to grow in advanced androgenetic

20 | Australian Doctor | 4 August 2017 www.australiandoctor.com.au alopecia, these areas are chosen for Figure 8. beneath the hair-bearing areas donor sites. This hair is likely to Before and of the scalp that lie next to bald continue growing for decades. after scalp areas. The device is then inflated Good quality donor tissue may micropigmentation. with saline water over a period of be hard to come by in people with weeks, which causes the skin to poor donor populations and in peo- stretch and grow new skin cells. ple who have had multiple previous Eventually, a visible bulge will transplantations. If poor quality appear on the scalp. When enough donor tissue is used, then balding skin is available, the surgeon will may occur in the grafts. excise the bald spot and bring Patients undergoing hair trans- together the stretched skin with plantation have an ongoing require- minimal tension. ment for medical therapy to arrest further loss in the scalp adjacent to Pre-operative assessment and the recipient site and to avoid the planning need for future additional surgery. The surgeon will give the patient Without medical therapy, andro- specific advice on how to prepare genetic alopecia is progressive and for the operation. When it is safe repeat operations will be required to spaced apart by several months to to do so, aspirin should be ceased compensate for ongoing loss. This allow the scalp to recover before the A 10-14 days prior to surgery. was the norm prior to the introduc- next procedure (see figure 9). Patient need to be aware that the tion of finasteride 15 years ago. Once the hair follicle has been surgery is very noticeable for the There is rarely sufficient donor hair inserted, it is normal for it to first two weeks, and that all hair population for more than three pro- undergo a stress reaction where the replacement techniques result in cedures. Since finasteride became hair follicle cycles and enters telo- some scarring. Patients will require widely available, fewer than 15% gen. The telogen follicle sheds the a full day off work for the surgery. of patients require repeat hair trans- hair fibres within a few weeks of Most people prefer to take a week plantation surgery. the operation. After approximately off after the surgery to allow for three months of telogen where the healing of the implants and for Follicular unit transplantation follicle remains empty, the anagen the bruising to reduce before they Strip harvesting is used to obtain phase of follicular growth com- return to work. Scarring is usually donor tissue for follicular unit trans- mences and the hair fibre regrows hidden by the growing hair. There Figure 9a. Before hair transplantation. plantation. Strip harvesting involves at a rate of 1cm per month. As are many horror stories on the inter- excision of a 10cm long strip of skin such, it takes 6-9 months before the net and in popular culture about from the occipital scalp. Pre-opera- patient can observe the full benefit B problems with hair transplanta- tively, the hair on the donor site is of the transplantation. Occasion- tion. Most of these relate to the ear- trimmed short to allow easy access ally, transplanted hairs do not sur- lier techniques of ‘punch’ grafting, (see figure 7). After the procedure vive and therefore do not produce which is not aesthetically acceptable patients are required to wear a pres- hair fibres. This is uncommon with by today’s standards. Newer tech- sure bandage for 24 hours to reduce good operators. niques using ‘mini’ grants, ‘micro’ bruising. The wound is closed pri- Most patients are able to toler- grafts and follicular unit transplants marily using a specialised tricho- ate the entire hair transplantation yield much better cosmetic results. phytic closure to conceal the scar. procedure under local anaesthetic. Follicles can also be transplanted A sedative may be used. Sedatives Post-operative care into the scar to further disguise the commonly produce temporary Immediate post-operative care scar. Scalp micropigmentation is amnesia. Saline with ATP is sprayed onto the another technique to conceal donor grafts for two days, then antiseptic site scars (see figure 8). Follicular unit extraction shampoo for a week, then back to Using a dissecting microscope, a Follicular unit extraction, or the Figure 9b. After hair transplantation. normal shampoo and activity. Con- team of 2-8 technicians then divides Woods technique, is an alternate tact sports may be resumed after the harvested strip of scalp tissue strategy to harvest donor tissue one month. Complications are rare. into individual follicular units. This using multiple tiny punch biopsies. A Minor shock loss from the surgery process may take up to eight hours, Each biopsy is around 0.75mm in at two weeks and a few pimples depending on the donor hair den- diameter. Great care is required to (folliculitis) may form as the hairs sity in the strip and the number of angle the biopsy in line with the begin to grow out at two months. technicians available. The follicu- angle of the follicle to avoid tran- Both of these complications usually lar units are counted and sorted in section. Each biopsy yields a single resolve but may present to the GP 1-hair, 2-hair and 3-4-hair units for follicular unit. Multi-hair units are as a patient concern. Diminished implantation. Individual follicular selected preferentially. The wound growth may also present. Refer units are implanted one by one into heals by contraction and secondary these patients to their treating spe- very small surgical incision sites in intention (see figure 10). cialist for management. the thinning or bald areas using This is the procedure of choice for either a needle or an implantation patients who have a buzz cut and Long-term care device. will not tolerate an occipital scar. Figure 10a.FUE donor site after harvesting 500 follicular units. Treat the new growth exactly the In most men, a 1cm-wide strip It has become increasingly popular same as non-transplanted hair, no harvested form the occipital scalp over recent years and now accounts B special care is needed. However yields between 1000 and 2000 folli- for around 40% of transplantation non-transplanted hair can recede cular units, depending on the donor procedures performed in Australia. from these grafts if stabilising medi- hair density. Women tend to have The yield of donor follicular units cation is not taken. a more diffuse pattern of hair loss is generally less than with follicular and generally yield 750-1500. unit transplantation, with the latter Transplantation for eyebrows The larger follicular units are the preferred procedure for women There are many eyebrow shapes used over the vertex scalp to recre- and men who wear their hair long and styles. Eyebrows have much ate maximal hair density, while the at the back. more variation than scalp hairlines. single hair ones are used to recreate Overharvesting can be unsightly. Male eyebrows sit at the orbital the anterior hairline. The surgeon Scalp micropigmentation is helpful rim but female eyebrows often rise takes great care when implanting in these cases. above the rim, some with a high the grafts to ensure they grow in arch and others flat. There is usu- the natural direction. Even the most Scalp reduction surgery ally some hair left in the eyebrows experienced surgeons find that rec- Scalp reduction surgery involves to guide surgeons in setting out the reating a natural frontal anterior removing the bald scalp and sew- area for graft implantation. The hairline is difficult and this is the ing it together end to end. The skin surgeon first needs to define the most operator dependent part of tends to stretch up to fill the defect Figure 10b. FUE recipient site after placement of 250 follicular units. medial starting point, the location the procedure. Choosing a surgeon left by the removed scalp and this of the arch and the lateral ending carefully is, therefore, of paramount can be used to rapidly decrease the been performed. This scar has the expanders. The technique of tissue point. There is a herringbone pat- importance. size of the bald patch. It can be used potential to become more notice- expansion has been developed to tern of growth, with the lower hairs Two or three sessions, each 4-8 as a stand-alone technique for small able as the balding progresses. repair burns or other injuries that growing upwards and the upper hours, may be required to achieve areas or complemented by hair Patients should keep this in mind have led to large areas of skin loss. hairs growing downwards. complete coverage in men with transplantation for larger areas. when considering such treatment. It can also be applied to disguise Eyebrow loss can be secondary stage 5 androgenetic alopecia and The scalp will, of course, have a Scalp reduction surgery can be hair loss. The procedure involves a to trichotillomania, alopecia areata, these procedures may need to be scar where the tissue reduction has augmented with the use of tissue balloon-like device being inserted cont’d next page

www.australiandoctor.com.au 4 August 2017 | Australian Doctor | 21 How to Treat– Hair restoration

from previous page A B C Online resources frontal fibrosing alopecia, hypo- thyroidism or simply chronologi- Better Health Channel cal ageing. It is prudent to establish Hair the cause of eyebrow loss prior to http://bit.ly/2ncXwTi transplantation and ensure the con- dition is in remission, otherwise the Hair transplant surgery new hairs will be in danger of being http://bit.ly/2oKJENf lost. Hair transplants can replicate Figure 11. Micropigmentation of the eyebrow. A. Before B. After the first session and C. After the second session. Patterned hair loss the natural growth and direction http://bit.ly/2p33cvx of eyebrow hairs. However, there is Befotre After no donor hair population that has The Conversation the exact same growth characteris- Health Check: why does women’s tics as eyebrow hair. Hair from the hair thin out? scalp behind the ears is closest in http://bit.ly/2p2NHDZ terms of fibre diameter, but it has a longer anagen duration, that is, it Starting to thin out? Hair loss doesn’t continues growing and requires reg- have to lead to baldness ular trimming. Hair follicle donor http://bit.ly/2obWB4W grafts are prepared in the same way as for scalp transplantation, except Australia | International Society of that the hairs are trimmed no Hair Restoration Surgery shorter then one centimetre long to http://bit.ly/2tC9cBa show the direction of the curl of the hair. They are implanted as flat as Biofibre artificial Hair — Medicap possible because the healing process http://bit.ly/2o4RFOW raises their exit angle of growth. At the time of implantation, it is very important to orientate the grafts References with the curl towards the skin. Available on request from Incorrectly orientated hairs end up [email protected] growing outwards with the curl away from the skin. Electrolysis is the best way to manage these errant hairs. A well-transplanted eyebrow Before and after (right side). gives much pleasure, but a poor result is a disaster as it is very vis- Figure 12. Scalp reduction surgery for frontal fibrosing alopecia. A thin strip of forehead skin is excised. An ible. For this reason, many patients advancement flap is used to move the hair line anteriorly and the wound is sutured. lean towards tattooing the eye- brows as a more predictable tech- nique for managing eyebrow hair mal timing of the procedure. two adjustments, growth is usually hairline, behind the ears and in loss (see figure 11). Procedures for secondary cica- satisfactory. Scalp micropigmenta- the nape of the neck. Typically the tricial alopecia due to accidents, tion (fine tattoo) can be used as an eyebrows are lost first and some Transplantation for cicatricial burns, facelift, radiation- induced adjuvant procedure to create the months to years later the hairline alopecia hair loss and pressure alopecia can appearance of increased density. recedes. Medical treatment can be This is a contentious area with proceed immediately. Those for Scalp expansion will be necessary used to stabilise the hair loss. How- wide differences of opinions among traction alopecia and trichotilloma- when the loss of hair approaches ever, the hair that is lost cannot be practitioners. The discord revolves nia can proceed once the traction 50%. When hair loss exceeds 50%, retrieved so surgical correction is around the susceptibility of the and pulling has stopped. a well-made hairpiece may be the the only way to restore hair. transplanted hairs to the underlying Scalp mobility is variable. In best option for the patient. If excision of the alopecia and condition that caused the cicatricial some patients with highly mobile primary closure is possible, scalp alopecia. Most surgeons will only scalp, large patches of cicatricial Scalp reduction for frontal reduction surgery provides an operate when there has been no alopecia may be amenable to sur- fibrosing alopecia instant fix. With some preparation progression of the cicatricial alope- gical excision. Serial excision may Professor Steven Kossard first to loosen the scalp, an advancement cia for at least two years.19 be used when there is less scalp described frontal fibrosing alope- of 2-3cm is possible (see figure 12). High-quality serial scalp pho- mobility. Hair follicle transplanta- cia in 1994.20 While once rare, this The lowered hairline changes the tography is required to be certain tion into the resulting scar and any condition is now the most common facial appearance dramatically. the scalp inflammation is in remis- smaller areas can be performed as a cause of cicatricial alopecia world- Transplantation is an alternative to sion. The classification of primary subsequent procedure. wide.21 The increasing prevalence scalp reduction surgery for frontal inflammatory cicatricial alopecia is Follicle transplantation is used has been attributed to the daily fibrosing alopecia, but takes much complex, the natural history vari- for patients with minimal scalp application of sunscreens to the more time to produce this effect and able and the management often mobility. Two to three sittings may forehead.22 Women over 50 are is more costly. The success of both unsatisfactory. Lupus, lichen plan- be required for extensive areas of most commonly affected and these surgical treatments relies on ongo- opilaris, frontal fibrosing alopecia alopecia. The vascularity in the women have often been applying ing medical therapy to maintain and folliculitis decalvans are the patches of cicatricial alopecia is moisturisers and day creams con- remission of the frontal fibrosing most common causes of primary often less than in normal scalp. As taining sunscreen to their face every alopecia process. If medications are cicatricial alopecia. Multidiscipli- a result, less adrenaline is required day summer and winter for decades. stopped, it can recur and damage nary care involving dermatologists for vasoconstriction and implants Frontal fibrosing alopecia is a the new anterior hairline. This, in and hair transplantation surgeons need to be spaced further apart lymphocyte mediated scarring alo- turn, will expose the scalp reduc- is required to determine the opti- than in a normal scalp. With these pecia that destroys follicles in the tion surgery scar.

The future

Hair cloning aggregates can be implanted into reform an aggregate that is capable tive capacity and there is no fur- fibres do not regrow once cut or THE ultimate goal of hair clon- human skin and induce hair fol- of inducing hair follicle neogenesis. ther spontaneous cell aggregation. change colour as the patient goes ing is to excise a single follicle in licle formation. The major limit- At this stage, however, there has There has recently been some pro- grey. The fibres generally only last a punch biopsy, isolate the dermal ing step occurs when the dermal been no cell division or expansion gress in this regard, however, fur- 5-10 years. In the author’s experi- papilla cells from that single hair papilla aggregates are cultured in of dermal papilla cell numbers. ther work is required before human ence, around 5-15% of patients follicle, expand the cell population vitro, where they initially disag- If left longer in a culture medium trials can commence. develop a foreign body reaction in culture and then re-implant mul- gregate and form a monolayer on the cells again disaggregate into a that requires removal of the fibres. tiple cultured dermal papilla into the surface of the culture medium. monolayer and the dermal papilla Artificial fibres Regular maintenance is required the skin. Each papilla would then Cells in a monolayer are unable cells start to proliferate. A 100,000- Artificial biofibres are an attrac- to extract comedos that build up induce differentiation of the overly- to induce hair follicle neogenesis fold expansion in cell numbers can tive concept for hair replacement. where the fibre exits the skin. Fur- ing epidermis into multiple termi- when implanted into human skin. occur before cells senesce. Unfor- The results are instantaneous and ther work is required to produce nal hair-producing scalp follicles. After a few days in the culture the tunately, cell expansion occurs patient satisfaction is very high ini- less reactive fibres. Presently, isolated dermal papilla dermal papilla cells spontaneously with the loss of hair follicle induc- tially. The limitation is that these cont’d page 24

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Case study Conclusion

GEORGE is a 48-year-old recent procedure under local anaesthetic THE vast majority of patients divorcee. He had been aware of without sedation. One thou- affected by patterned hair loss can progressive hair loss over a num- sand 0.75mm donor grafts were be effectively treated with a com- ber of years. He initially trialled removed from his occipital scalp bination of medical, surgical and topical minoxidil, but found that and the wound left to heal by sec- camouflage techniques. Patients eight months of therapy produced ondary intention. who start treatment early do bet- no visible increase in hair density The grafts were inspected for ter and may manage with medi- and so discontinued therapy. He transection, further microdis- cal therapy alone. Patients with subsequently consulted his GP sected into follicular units and advanced hair loss should only about his hair loss and was pre- each graft was then individually be considered for hair restora- scribed finasteride 1mg daily. He implanted into an incision made tion surgery after having been on was intolerant of this treatment with a 19 or 20 gauge needle. The medical therapy for 6-12 months. because of loss of libido and erec- scalp was cleaned and dressed This is to stabilise the hair loss and tile dysfunction. Libido and sex- and George was discharged home improve donor site hair density. As ual function returned to normal after six hours. patterned hair loss is a progressive two months after discontinuing He was able to wash his hair condition when untreated, medical the treatment. after 24 hours. At one week, the therapy should be continued long He was referred to a dermatolo- recipient site wounds had healed term after hair restoration surgery gist who prescribed oral minoxi- and at two weeks, the donor site to prevent balding in the hairs dil 0.5mg daily. His hair loss was wounds had healed and were con- adjacent to the implants. arrested and over 12 months there cealed by hair regrowth. was partial regrowth of his vertex At three months, new hairs and frontal hair. began to emerge from the Conflict of interest statement George then consulted a hair implanted follicles. At 12 months, Professor Sinclair is a dermatologist. transplant surgeon who assessed the scalp coverage was complete. Dr Marzola is a hair transplant him as a suitable candidate for George continued to take oral surgeon. hair transplantation. After con- minoxidil and was advised the sidering the surgical options, he medical therapy should be con- elected to have the follicular unit tinued long-term to maintain hair extraction procedure as a day density.

How to Treat Quiz GO ONLINE TO COMPLETE THE QUIZ Hair restoration — 4 August 2017 www.australiandoctor.com.au/education/how-to-treat

1. Which TWO statements regarding the due to miniaturisation of secondary follicles sexual dysfunction. d) Without medical therapy, androgenetic background to hair restoration are correct? over the frontal and vertex scalp. alopecia is progressive and repeat a) The principle of donor dominance states d) Body hairs are tufted and arise from 6. Which THREE are features of oral operations will be required to compensate that the behaviour of transplanted hairs is complex pilo-sebaceous units comprising finasteride? for ongoing loss. determined by the characteristics of the one primary hair, up to five secondary hairs a) There are no significant drug interactions donor site rather than the recipient site. that bud off the side wall of the primary and the main toxicity relates to adverse 9. Which TWO statements regarding hair b) The field of hair transplantation has not seen follicle, a single sebaceous gland and a sexual side effects. replacement surgery are correct? any major advances in the past 15 years. single arrector pili muscle. b) The sexual side effects are always reversible a) Strip harvesting is used to obtain donor c) Men and women with advanced on discontinuation of the drug. tissue for follicular unit transplantation. androgenetic alopecia can be managed 4. Which THREE statements regarding the c) Higher doses do not improve efficacy, but b) Once the hair follicle has been inserted, it is effectively with a combination of medical patterns of baldness are correct? are associated with more frequent and normal for it to shed the hair fibres within a therapy and hair transplantation surgery. a) Baldness occurs when all the hairs within severe adverse sexual side effects. few weeks of the operation. d) Follicular unit transplantation accounts for a complex pilo-sebaceous unit have d) Finasteride has a protective effect against c) Follicular unit extraction is the preferred over 95% of transplants in men. miniaturised to the point of invisibility. future development of low-grade prostate procedure for women and men who wear b) Baldness over the temples begins at the cancer. their hair long at the back. 2. Which THREE statements regarding anterior hairline and moves posteriorly. d) It takes three months after follicular patterned hair loss are correct? c) On the vertex scalp, miniaturisation 7. Which TWO of the following may also unit transplantation before the patient a) The pattern of hair loss in men (male pattern progresses circumferentially to produce an increase scalp hair density? can observe the full benefit of the hair loss) and women (female pattern hair expanding bald patch. a) Prostaglandin antagonists. transplantation. loss) are relatively constant. d) On the vertex scalp, baldness begins at the b) Serial injection of platelet-rich plasma. b) In Australia there are estimated to be about anterior midline and moves laterally to create c) Low-level laser devices. 10. Which THREE statements regarding hair four million balding men. the so-called Christmas tree pattern. d) Prostanoids. replacement surgery are correct? c) Premature hair loss is defined as hair a) Lupus, lichen planopilaris, frontal fibrosing loss that exceeds normal age-related 5. Which TWO statements regarding 8. Which THREE statements regarding hair alopecia and folliculitis decalvans are the androgenetic alopecia. medical therapy are correct? replacement surgery are correct? most common causes of primary cicatricial d) Premature hair loss may diminish physical a) The goal of medical therapy is to restore a a) Scalp reduction procedures are useful alopecia. attractiveness. full head of hair identical to that prior to the for people who wish to achieve a modest b) It is prudent to establish the cause of hair loss. change in the fullness of their hair. eyebrow loss prior to transplantation 3. Which TWO statements regarding b) Known side effects of topical minoxidil b) Hair transplantation involves removing donor and ensure the condition is in remission, patterned hair loss are correct? include irritant and allergic contact hair from the hair-bearing occipital scalp and otherwise the new hairs will be in danger of a) Premature androgenetic alopecia has a dermatitis, hypertrichosis and a temporary relocating it to bald or thinning areas over being lost. monogenetic aetiology. telogen effluvium on initiation of therapy. the temples, frontal or vertex scalp. c) Frontal fibrosing alopecia is most commonly b) Epigenetic silencing of the androgen c) Finasteride and dutasteride are safe in c) High-quality donor tissue may be hard seen in women over 50. receptor gene on the occipital scalp protects women of child-bearing age. to come by in people with poor donor d) Eyebrow hair grows in a ‘fern pattern’, these follicles form the balding process. d) Spironolactone and cyproterone acetate populations and in people who have had with all hairs growing upwards, making c) The initial loss in androgenetic alopecia is are contraindicated in men because of multiple previous transplantations. transplants easy and quick to perform.

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