Optimizing Skin Grafting Using Hair-derived Skin Grafts: The Healing Potential of Hair Follicle Pluripotent Stem Cells.

BACKGROUND: A man in his 60s with recurrent venous leg ulcers (VLUs) presented with an 18-month history of a VLU on his medial left leg measuring 59.3 cm(2). He had been treated with multi- component compression bandages without significant decrease in ulcer size. Given the ulcer's size, refractory nature, and history of recurrence, the authors sought to optimize the patient's healing. METHODS: Approximately 23% of the total wound was treated using punch grafts (PGs) harvested from different locations on the body based on hair density using the "stick and place" method. RESULTS: One month later, a 56% reduction in ulcer size was observed, especially in the area that received hair-bearing skin. CONCLUSION: Punch grafts from hair-bearing skin are a viable source of follicular stem cells and may be superior to PG from nonhair-bearing skin for the treatment of chronic wounds.

Lichen Planopilaris in the Androgenetic Alopecia Area: A Pitfall for Hair Transplantation.

BACKGROUND: Classic lichen planopilaris (LPP) is a patchy form of primary lymphocytic cicatricial alopecia localized on the vertex of the scalp. It is important, however, to be aware of other, less recognized presentations that may be missed without dermatoscopy and pathology. METHODS AND RESULTS: We report 26 patients with LPP presenting with subtle erythema and scaling colocalized in the area of patterned thinning (androgenetic alopecia, AGA). All patients had been treated for seborrheic dermatitis in the past. Dermatoscopy showed the presence of 2-4 hairs emerging as a tuft from the same ostium surrounded by erythema, peripilar casts and interfollicular scaling associated with hair miniaturization. Histopathology obtained from those areas corresponded to LPP with concomitant follicular miniaturization. CONCLUSION: Subtle or focal cases of LPP may be missed for seborrheic dermatitis when overlapping with AGA. Dermatoscopy-guided biopsy from the affected scalp is the best approach to make a timely diagnosis. This is particularly important in patients with AGA evaluated to undergo hair transplantation, as active LPP is a contraindication for these patients.

Robotic hair restoration.

The latest innovation to hair restoration surgery has been the introduction of a robotic system for harvesting grafts. This system uses the follicular unit extraction/follicular isolation technique method for harvesting follicular units, which is particularly well suited to the abilities of a robotic technology. The ARTAS system analyzes images of the donor area and then a dual-chamber needle and blunt dissecting punch are used to harvest the follicular units. The robotic technology is now being used in various locations around the world. This article discusses the use of the robotic system, its capabilities, and the advantages and disadvantages of the system.

Nonsurgical therapy for hair loss.

This article is an update of the currently available options for medical therapies to treat androgenetic alopecia in men and women. Emerging novel therapeutic modalities with potential for treating these patients are discussed. Because androgenetic alopecia is progressive in nature, stabilization of the process using medical therapy is an important adjunct to any surgical hair-restoration plan.

Caspase-1 level is higher in the scalp in androgenetic alopecia.

BACKGROUND AND OBJECTIVES: Inflammasomes that activate caspase-1 govern the innate immune inflammatory response. Whether hair loss associated with androgenetic alopecia (AGA) involves caspase-1 activation is not known. METHODS: Immunohistochemical staining for caspase-1 was performed on scalp tissue sections, and protein lysates were analyzed from individuals with AGA (no treatment), and individuals with AGA taking finasteride with apparent hair growth, individuals with AGA taking finasteride without noted hair growth, and normal controls. In vitro studies of human keratinocytes were conducted to establish effects of finasteride, dihydrotestosterone (DHT), and testosterone on caspase-1 levels using immunoblot analysis. RESULTS: Caspase-1 is expressed in normal human adult epidermal keratinocytes. Caspase-1 expression is greater in men with AGA. In contrast, in men taking finasteride, caspase-1 levels were lower and were similar to those in normal controls. In vitro studies showed that keratinocytes treated with finasteride in combination with testosterone or DHT resulted in a significant decrease in caspase-1 expression. CONCLUSION: In vivo and in vitro finasteride treatment resulted in lower caspase-1 expression, supporting the idea that androgens influence innate immunity involved in the hair cycle in AGA. These findings may provide a basis for development of novel treatments for inflammatory skin and hair diseases.

Naturally occurring female hairline patterns.

BACKGROUND: Hair transplantation is gaining popularity in women. Although much has been written about hairline design in male patients, more information is needed about natural female hairlines. OBJECTIVE: To determine the frequency, dimensions, and location of structures that compose the female hairline. METHODS: Hairline characteristics were measured in 360 female volunteers at an informal hair salon setting. RESULTS: A widow's peak was present in 81%. The mean distance from the mid-eyebrow to the frontal midpoint was 5.5 cm. Lateral mounds were observed in 98%. The mean distance from the frontal midpoint to the apex of the lateral mounds was 3.74 cm on the right and 3.97 cm on the left. The mean distance from the apex of the lateral mounds to the apex of the temporal points was 3.78 cm on the right and 3.51 cm on the left. The shape of the temporal recessions was concave triangular or concave oval in 87% of the subjects. CONCLUSION: This study provides proposed guidelines for designing the hairline in women.

Techniques to reduce pain associated with hair transplantation: optimizing anesthesia and analgesia.

The importance of pain control in hair transplantation cannot be overemphasized. Adequate preoperative sedation to reduce anxiety, raise pain threshold, and induce amnesia is fundamental to minimizing operative pain. Most of the pain associated with the procedure results from injection of the local anesthetic. Once initial anesthesia is achieved, proper maintenance of anesthesia is of paramount importance especially with the trend toward larger numbers of grafts being performed in one session with prolonged operative times. The choice of local anesthetic agents, infiltration technique, optimal field blocks and nerve blocks, proper hemostasis, timely repetition of anesthesia, and use of analgesics intraoperatively, with the goal of maintaining the patient pain-free during the procedure, are fundamental. In addition, reduced pain on infiltration can be achieved with buffering and warming of the local anesthetic solution as well as techniques to decrease sensation or partially anesthetize the skin prior to injection. Techniques such as bupivacaine donor area field block in the immediate postoperative period and early administration of analgesics can greatly influence postoperative pain. Along with excellent cosmetic results attainable with modern techniques, improving patients' experiences during the surgical process will enhance the public perception of hair transplantation and will encourage prospective patients to seek this treatment modality.

Effects of finasteride on apoptosis and regulation of the human hair cycle.

BACKGROUND: A number of studies have provided evidence that apoptosis is a central element in the regulation of hair follicle regression. In androgenetic alopecia (AGA), the exact location and control of key players in the apoptotic pathways remains obscure. OBJECTIVE: In the present study, we used a panel of antibodies and investigated the spatial and cellular pattern of expression of caspases and inhibitors of apoptosis (IAPs), such as XIAP and FLIP, in men with normal scalp and in men with AGA before and after 6 months of treatment with 1 mg oral finasteride treatment. METHODS AND RESULTS: Constitutive expression of caspases-1, -3, -8, and -9 and XIAP was detected predominantly within the isthmic and infundibular hair follicle area, basilar layer of the epidermis, and eccrine and sebaceous glands. AGA-affected tissues showed an increase in caspase (-1, -3, -6, -9) immunoreactivity with a concomitant decrease in XIAP staining. After 6 months of finasteride treatment, both caspases and XIAP were similar to levels exhibited by normal subjects. Immunoblot analysis was performed to determine antibody specificity and cellular expression of caspases. Purified populations of keratinocytes, melanocytes, dermal papilla, and dermal fibroblasts derived from human hair follicles were cultured in vitro and treated with 0.5 mm staurosporin. Time-course experiments revealed that processing of caspase-3 is a principal event during apoptosis of these hair cell types. CONCLUSION: These data suggest that alterations in levels of caspases and IAPs regulate hair follicle homeostasis. Moreover, finasteride appears to influence caspase and XIAP expression in hair follicle cells thus signaling anagen, active growth in the hair cycle.