Hair transplantation versus scalp micropigmentation: A retrospective study of treatment selection in persons with female pattern hair loss.

BACKGROUND: Hair transplant (HT) is the standard treatment for female pattern hair loss (FPHL), but scalp micropigmentation (SMP) is an alternative. Currently, there are no criteria to help choose between HT and SMP. METHODS: Forty female patients with FPHL who had successfully undergone HT and SMP, were reviewed to identify factors that might help decide between treatments. Hair density (HD) and hair caliber were measured at the part line and mid-occipital region by a Folliscope. The sensitivity and specificity of HT and SMP were determined by area under the curve (AUC) and receiver operating characteristic curve. RESULTS: Patients were divided into HT (n = 23) and SMP (n = 17) groups. The follicular unit density (FUD) (HT: 62.06 ± 4.8551/cm2; SMP: 66.59 ± 3.4971/cm2) and HD (HT: 96.16 ± 16.6954/cm2; SMP: 116.08 ± 17.0520/cm2) were significantly different (p < 0.01) between groups. The AUC for FUD was 77.6% with a cutoff value of 66.83 and 87.0% (1-0.412) sensitivity. The AUC for HD was 82.4% with a cutoff value of 96.17 and 69.6% (1-0.118) sensitivity. CONCLUSIONS: HD was the most important factor when deciding between HT surgery and SMP. SMP is recommended when the HD is ≥104.6 hairs/cm2 and HT surgery is strongly recommended when the HD is ≤96.17 hairs/cm2.

Long hair follicular unit excision: personal experience.

BACKGROUND: Long hair follicular unit excision (FUE) is the most state-of-the-art surgical technique in the field of hair transplantation surgery. Long hair FUE reduces the signs of surgery by camouflaging the recipient area with long hair, and allows hair curl identification when placing grafts. In addition, donor area shaving can be omitted. METHODS: This article presents the surgical approach and methods of long hair FUE. Patients were categorized by sex, age, recipient site, purpose of the surgery, and history of previous hair transplantation. Medical charts and photographs were reviewed to obtain the transection rate and calculated density for each patient. RESULTS: Long hair FUE was applied to 134 patients (112 women and 22 men). Thirty-four patients received eyebrow hair transplantation, 73 underwent female hairline correction surgery, nine patients underwent sideburn reconstruction, two were treated for female pattern hair loss, and 19 were treated for male pattern baldness (MPB). Four of the patients with MPB also underwent eyebrow transplant surgery. Of the patients with MPB, 17 (89%) had Norwood type III baldness, and two (11%) had type IV hair loss. The mean number of grafts required was 292 for eyebrow transplantation, 1,214 for female hairline correction, 251 for sideburn reconstruction, 1,344 for female pattern hair loss, and 1,567 for MPB. The mean follicle transection rate was 9.2%, and the mean calculated number of follicles per graft achieved was 2.23. CONCLUSION: This long hair FUE method introduced by the authors is an excellent surgical method when performed by surgeons with sufficient skill and expertise.

Comparative Graft Survival Study of Follicular Unit Excision Grafts With or Without Minor Injury.

BACKGROUND: Various types of follicular trauma occur during follicular unit excision (FUE). However, the effects of different types of follicular injury on graft survival have not been reported. OBJECTIVE: This study was performed to evaluate the differences in hair follicle survival by the type of follicular injury, including paring, fracture, and bulb injury. METHODS: Seven healthy patients who underwent hair transplant surgery by FUE were enrolled in the study. For each patient, 10 single-hair follicular unit grafts per injury group (paring, fracture, bulb injury, or intact) were differentiated. Using sharp implanters, 10 grafts of each of the 4 injury types were transplanted into mice, and the mice were sacrificed 5 months after transplantation. The skin was excised at each of the 4 locations, and newly formed follicular units were counted and photographed under a microscope. RESULTS: Of 70 hair follicles in each group, the number of successfully engrafted follicles was 50 (71.43%) in the intact group, 36 (51.43%) in the paring injury group, 9 (12.86%) in the fracture injury group, and 31 (44.29%) in the bulb injury group. CONCLUSION: Grafts with minor injury had a lower survival rate than intact grafts. Fractured follicles showed the lowest survival rate.

Torsional and Bending Properties of V Taper 2H, ProTaper NEXT, NRT, and One Shape.

Nickel-titanium (NiTi) rotary files have enabled efficient root canal preparations that maintain the canal center with fewer aberrations compared to hand files. However, NiTi rotary files are susceptible to fracture, which can thereby compromise root canal treatment. Therefore, NiTi files have been developed to enhance fracture resistance by modifying design and thermal treatment. The objective of this study was to compare the torsional fatigue resistance and bending resistance of NiTi files manufactured from different alloys and treatments. ProTaper NEXT X2 (PTN; M-wire), V taper 2H (V2H; controlled memory wire), NRT (heat-treated), and One Shape (OS; conventional alloy) instruments of tip size #25 were compared. Torsional fatigue was evaluated by embedding the 3 mm tip of each instrument (N = 10/brand) in resin and the repetitive application of torsional stress (300 rpm, 1.0 N·cm) by an endodontic motor with autostop when the file fractured. The number of loading cycles to fracture was recorded and analyzed by Kruskal-Wallis and Mann-Whitney U tests with Bonferroni's correction. Bending resistance of the instruments was tested using a cantilever bending test to the 3 mm point from the tip (N = 10/brand). The stress was measured when deflection of 3 mm was subjected and statistically analyzed with a one-way analysis of variance and Tukey's honest significance difference test (α = 0.05). V2H withstood the highest number of load applications during torsional fatigue testing (p < 0.05), followed by NRT, PTN, and OS, where the differences between NRT and PTN (p=0.035) and between PTN and OS (p=0.143) were not statistically significant. V2H showed the lowest bending stiffness, followed by NRT, PTN, and OS (p < 0.001). Thermal treatment of NiTi wire resulted in improved mechanical properties, and controlled memory wire provided improved flexibility and torsional fatigue resistance.

Secondary Revision of Female Hairline Correction Surgery: Personal Experience.

Patients undergoing secondary female hairline correction surgery present with dissatisfaction of various causes that require specific solutions. Satisfactory results following secondary revision surgery are achieved only after consideration of the reasons for the patient's dissatisfaction as well as specific factors regarding the state of the hairline, height and width of the forehead, and overall facial type; all of these must be considered when choosing the most suitable surgical method. In the present study, the authors used various surgical approaches according to the patient's characteristics and presenting symptoms in the performance of secondary hairline correction surgery and evaluated the adequacy of each method using a satisfaction survey. In total, 246 patients who underwent hairline correction surgery by hair transplantation were enrolled in this study. As adjunctive procedures prior to surgery, 24 patients received triamcinolone injections every 1-2 weeks to ameliorate severe hyperfibrotic scarring, and laser hair removal was performed in part of the recipient area in 18 patients to remove old transplanted grafts that had created an awkward appearance or were unnecessary. Revision of female hairline correction surgery was performed with FUT (follicular unit transplantation) in 156 patients (63.4%), partial-shave FUE (follicular unit extraction) in 12 patients (4.9%), a combination technique (FUT + FUE) in 24 patients (9.8%), and non-shaven FUE in 54 patients (22.0%). 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 .

Shaved hair style scalp medical tattooing technique for treatment of advanced male pattern baldness patients.

BACKGROUND: The most infallible approach to male pattern baldness (MPB) is hair transplantation in the thinning area in parallel to medical treatment to prevent further alopecia progression. For an individual with advanced stage hair loss, a megasession surgery is recommended to meet the high donor hair requirement. Yet a most effective therapeutic regimen for alopecia, hair transplantation inevitably has its advantages and disadvantages for it is done with the expense of donor hair sacrifice, intraoperative and postoperative pain, and unavoidable scars. Also, with poor donor condition, surgery may not even be an option. Nowadays, more patients with such limitations are undergoing shaved style scalp medical tattoo (SMT). OBJECTIVE: To assess the effectiveness of SMT technique for shaved hair style. METHODS AND MATERIALS: A total of 80 patients who were included in the study underwent SMT for shaved hair style between June 2014 and June 2017 and were followed for at least 6 months afterward. Patients and the surgeon completed a survey about donor and recipient site surgical results using a 5-point Likert scale. RESULTS: The average satisfaction scores of patients and surgeon were 4.8 and 4.9, respectively. CONCLUSION: Shaved style SMT can be considered one of the most effective treatment methods for patients with advanced stage hair loss. LEVEL OF EVIDENCE: IV.

Nonshaven Follicular Unit Extraction: Personal Experience.

Nonshaven follicular unit extraction (NS-FUE) is the most state-of-the-art surgical technique in the field of follicular unit hair transplantation. It is particularly appealing because donor area shaving, one of the most serious impediments for the patient, can be omitted. In this article, we present our surgical approach for NS-FUE. We selectively used the direct or the pretrimming method of NS-FUE according to indication, determined by considering the location and purpose of transplantation, the condition of the recipient site, and the patient's preference. A total of 658 patients underwent NS-FUE. Of these, 17 had pubic atrichia, 2 had pubic atrichia and also received hairline correction surgery, 6 received eyebrow transplantation, 19 had female pattern hair loss, 362 had male pattern baldness (MPB), 2 had MPB and also required eyebrow transplantation, 3 received hair transplantation for MPB and scalp scar, 9 underwent male hairline correction surgery, 192 underwent female hairline surgery, and 46 received hair transplantation for scalp scar. The average numbers of transplanted grafts were 573 for atrichia, 1300 for atrichia and hairline correction performed successively, 240 for eyebrow transplantation, 996 for female pattern hair loss, 1408 for MPB (with a maximum of 3000), 1050 for MPB and eyebrow transplantation, 998 for female pattern hair loss (with a maximum of 1910), and 141 for scalp scar. On average, the total transection rate was 8.2%, and the calculated density was 2.2.

Various Types of Minor Trauma to Hair Follicles During Follicular Unit Extraction for Hair Transplantation.

BACKGROUND: When performing follicular unit extraction (FUE), various types of minor hair follicle trauma unapparent during follicular unit strip surgery are likely to occur. However, no studies have examined such damage. METHODS: In total, 100 grafts were randomly selected from each of 42 patients who underwent FUE with a 1-mm-diameter sharp punch. A ×5.5 magnifying loupe and a ×60 magnifying binocular microscope were used. The transection rate (TR), paring, fractures of and damage to the dermal papilla (DP) areas, and hair bulb partial injury were assessed. RESULTS: Observation with the magnifying loupe revealed an average TR of 7.40%, and 4.31, 1.90, 1.52, and 0.43 hair follicles per 100 grafts exhibited paring, fracture, DP partial injury, and hair bulb partial injury, respectively. An average of 9.21 telogen hairs were observed. Microscopic examination revealed a TR of 6.34%, and 9.07, 1.95, 0.79, and 1.24 hair follicles per 100 grafts exhibited paring, fracture, DP injury, and hair bulb partial injury, respectively. An average of 16.62 telogen hairs were observed. CONCLUSIONS: Various types of minor hair follicle damage occur during FUE as shown by loupe and microscopic examination of the grafts. Especially paring and hair bulb injury were more apparent under microscopic examination. These minor hair follicle injuries should be considered when choosing operative method or surgical techniques.

Pretrimmed versus Direct Nonshaven Follicular Unit Extraction.

BACKGROUND: Shaving the donor area is one of the major deterrents preventing hair transplant patients from selecting follicular unit extraction (FUE). A minimal shaved donor area is possible in strip surgery, but the strip method is not applicable if the patient wishes to avoid a linear donor scar, wishes to minimize postoperative pain, or has insufficient scalp laxity. In these cases, nonshaven FUE (NS-FUE) is potentially a very good choice. METHODS: A total of 42 patients were enrolled. Both pretrimmed and direct NS-FUE were performed during a single session in each patient. The 2 methods were compared regarding the time taken to punch 50 grafts, transection rate, and calculated density (number of hairs per graft). RESULTS: The mean time taken to punch 50 grafts was significantly longer in the pretrimmed method than the direct method (3.4 minutes versus 2.6 minutes; P < 0.001). The mean transection rate was similar in both methods (8.8% for the pretrimmed method and 7.5% for the direct method; P > 0.05). The mean calculated density was significantly higher in the pretrimmed method than the direct method (2.23 hairs per graft versus 2.15 hairs per graft; P < 0.05). The length of the harvested hair was 1-4 mm in the pretrimmed method, compared with 0.4-0.8 mm in the direct method. CONCLUSION: Depending on the proficiency and preference of doctors and the case indications, pretrimmed and direct NS-FUE are both useful techniques for hair transplantation.

Photo Epilation with Intense Pulsed Light for Thinning of Anterior Hairline after Hairline Correction Surgery in East Asians.

BACKGROUND: Thin hairs are critical to achieve natural result in female hairline correction surgery. However, there are few studies on the usefulness of hair thinning by intense pulsed light (IPL) after hairline correction surgery in East Asian females. METHODS: Hair thinning using IPL was performed in 54 women who had complained about thick hairs along the frontal hairline after hairline correction surgery. Patient mean age was 31.2 years old and patients were an average of 2.1 years post-hairline correction surgery. Initial treatment used 10 J, while second and third sessions were conducted with 10 to 15 J according to responsiveness to treatment. RESULTS: Mean thickness of individual hairs assessed before the procedure was 78.86 µm. The mean number of procedures was 1.6 per patient. Forty of 54 subjects (74%) achieved satisfactory hair thinning with only one procedure from 78.01 to 66.14 µm after treatment. The measured thickness was 66.43 µm at the end of the first year in patients who were satisfied after one procedure. Thirteen cases achieved satisfactory hair thinning after two sessions. Mean thickness was 74.44 µm and 67.51 µm, before and after the second session. One case required a third session with 15J, thinning from 89.00 to 66.50 µm. CONCLUSIONS: Hair thinning by IPL is a very useful method to provide a natural look after hairline correction surgery in East Asians, who have naturally thick hair.

Scalp Medical Tattooing Technique to Camouflage Bifid Parietal Whorls.

BACKGROUND: To the best of the authors' knowledge, no reports have described cosmetic problems arising from the hair direction around the parietal whorl (PW). This study was performed to evaluate the efficacy of scalp medical tattooing technique for camouflaging bifid PWs. METHODS: We retrospectively examined the outcomes of scalp medical tattooing in 38 patients who were admitted for camouflage of a bifid PW. RESULTS: All patients' cosmetic appearance was judged, by both the patients and the surgeon, to be markedly improved. No specific complications occurred, such as infection, hair loss in the operative field, or other problems. CONCLUSION: Scalp medical tattooing appears to be an effective method that helps to camouflage the see-through appearance of bifid PWs.

Predicting the Permanent Safe Donor Area for Hair Transplantation in Koreans with Male Pattern Baldness according to the Position of the Parietal Whorl.

BACKGROUND: The most crucial factor in hair transplantation for male pattern baldness (MPB) patients is the efficient utilization of the donor-recipient ratio. However, there is no known factor that scientifically predicts the rate of progression of alopecia or indicates a permanently safe donor area. METHODS: The study considered 1,008 Korean adult males with MPB; of these, it excluded 56 males with an absence of parietal whorls (PWs). The authors investigated the distance from the vertical bimeatal line (VM) to the PW, from the PW to the upper border of the helical rim (HR), and the distance from the PW to the occipital fringe (OF) in 952 subjects with a PW. Furthermore, we examined the distance from the PW to the OF considering the duration of alopecia and age in 322 subjects with vertex alopecia. RESULTS: The distance between the VM and PW varied from 1.5 to 11 cm, with an average distance of 6.25 cm. The PW-HR distance ranged from 3.4 to 17.5 cm, and the average distance was 7.79 cm. The PW-OF distance ranged from 0.5 to 5.5 cm, and the average distance was 2.37 cm. CONCLUSIONS: For the PW, very large variations existed in the vertical direction. The position of the PW could predict the progression range of the total alopecia of the vertex. Alopecia mostly progresses within 6 cm of the PW toward the occipital side.

Micropigmentation: camouflaging scalp alopecia and scars in Korean patients.

BACKGROUND: The aim of this study was to identify the usefulness of micropigmentation as a technique for alopecia and scalp scar camouflage in Korean patients. METHODS: Micropigmentation was performed in 43 Korean patients from November 2011 to October 2012. There were 23 female patients with female pattern hair loss (FPHL), 14 male patients with male pattern baldness, and 6 patients with scalp scars. RESULTS: The results for one patient with FPHL Ludwig stage I were satisfactory according to the physician's assessment, but the patient was dissatisfied because she did not notice any remarkable changes after the procedure. The results for the other 42 patients were highly satisfactory and there were no adverse effects or complications. CONCLUSIONS: Micropigmentation appears to be a good method for camouflaging hair loss and scalp scars. 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 .