The Juri Flap was the most popular flap, a pedicled temporo-parieto- occipital flap that was 20–25 cm long and 4 cm wide that was mobilized, rotated, and sutured in the hairline area to create an entire frontal hairline. These technically challenging procedures provided immediate and “impressive” results but did so at the expense of naturalness and long-term goals. They fully depleted the donor area and only allowed the creation of an unnaturally thick, abrupt hairline.
An overgrowth of scar tissue at the site of a wound in the skin.
An anti-fungal agent. Ketoconazole in high oral doses has antiandrogenic and anti-glucocorticoid properties, inhibits the production of Testosterone and other androgens in both gonads and adrenals. It is used topically for the treatment of seborrheic dermatitis and dandruff and is believed to stimulate hair growth. Ketoconazole shampoo acts synergistically with Finasteride and Minoxidil, it is considered very safe, tolerable, and valuable addition to every AGA/FPHL patient even though the quality of evidence of its efficacy is still poor.
Lanugo hair is the first hair growth produced by the developing hair follicles during intrauterine life, it is fine, soft, poorly pigmented, or colorless and has no central medulla. Lanugo hair growth is usually shed between the 32nd and 36th weeks of gestation. However, in 30% of fetuses, it is retained until birth, to some extent.
The coronal incision is produced at a right angle to the direction of the hair. Coronal grafting causes less vascular trauma, less scarring, and less elevation of the skin. Additionally, there is less popping of grafts due to reduced displacement forces, faster healing because of smaller incisions, and maximum coverage since grafts are placed closer together in an interlocking fashion. The lateral slit technique gives the hair restoration surgeon the ability to control the angle, direction and orientation of the transplanted hair.
Schematic of sagittal vs. coronal incisions. Hair direction is also represented with blue arrows. The right side shows coronal incisions made at right angles to the direction of hair growth. The left side demonstrates that sagittal incisions made parallel to the direction of growth.
An autoimmune disorder that causes a permanent scarring alopecia. Adult women make up the majority of the LPP patient population. It is the most common primary cicatricial alopecia and results in a shiny alopecia of the mid-scalp, vertex, or parietal areas. According to the severity of disease, treatment options include corticosteroids, hydroxychloroquine and immunomodulating agents.
Liposomal-encased ATP (Energy Delivery Solutions LLC, Jeffersonville, IN) is claimed to compensate for the first 4-5 days after HRS during which here is a lack of oxygenation by providing energy to the cells. The liposomal ATP is also supposed to act as a vasodilator, bringing in additional nutrients and decreasing reperfusion injury. Studies on the use of Liposomal ATP are limited, but they suggest an increase in graft survival, and there are anecdotal reports of better graft growth and earlier growth. Liposomal ATP is used as an additive to the holding solution and as a post-operative spray.
A disorder predominantly diagnosed in children, often receding with age.
Low-level laser therapy (LLLT) comprises of low-energy laser treatment—in the range of a few mW—which results in photo-biomodulation effects through the absorption of light photons by tissue photoacceptors to stimulate a biologic response. There are various hypotheses about the mechanism of LLLT in promoting hair growth and the exact mechanism of action is still controversial. Several clinical studies and meta-analyses have been published since 2007, all reporting positive results, some comparable to established FDA-approved hair growth treatments. LLLT devices are easy to apply, have high patient compliance, are safe and effective in patients with AGA/FPHL as both an individual therapy, an adjuvant to standard FDA-approved treatments, even useful in hair transplant surgery for its ability to promote graft survival.
As far as Female Pattern Hair Loss (FPHL) is concerned, Ludwig established in 1977 the three main stages of the FPHL phenotype in women, which are divided into three categories of severity each. According to the classic publication by Erick Ludwig, hair loss in women begins with uniform thinning (coined “rarefaction” by the author) of the crown. According to Ludwig, FPHL progresses with uniform miniaturization of hair follicles in the central-temporal areas and ends up as an oval-shaped area of thin hair, surrounded by a circular band of hair with a variable breadth and normal density.
Graphic presentation of Ludwig pattern of FPHL, with a typical example for each grade (a) Grade I. Perceptible thinning of the hair on the crown, limited in the front by a line situated 1–3 cm behind the frontal hair line. (b) Grade II. Pronounced rarefaction of the hair on the crown within the area seen in Grade I (c) Grade III. Full baldness (total denudation) within the area seen in Grades I and II. (Adapted with permission from Ludwig).
Refers to transplanting a large number of follicular unit grafts in a single session. Even though there is no established, official definition of a megasession, most surgeons would agree that the term describes transplanting a vast number of grafts, usually >3000 FUs, in one session. During modern megasessions, 3000–5000 FUs can be transplanted in one sitting, and the goal is to cover all recipient areas densely in “one-pass.” There are strong arguments favoring megasessions: more dramatic results, fewer sessions required, fewer donor area incisions, better graft yield, less overall patient discomfort and downtime, no “plugginess” or “see-through” between surgeries, higher patient convenience and satisfaction, lower cost/ graft, and higher overall value.
Melatonin is a neurohormone released by the pineal gland regulating seasonal biorhythms, daily sleep cycles, and the aging process. Along with circadian rhythm function, melatonin is a potent radical scavenger maintaining the functional integrity of cells with its antioxidant properties. Regarding the in vivo action of melatonin on human hair follicles, data are limited, and trials on topical effects of melatonin in AGA/FPHL and diffuse alopecia are small, poorly designed, biased, suffering from conflicts of interest and the reported results are suspiciously “impressive”.
Mesotherapy consists of superficial scalp injections of pharmaceuticals and vitamin compounds that have been previously been used to treat hair loss via the topical or systemic routes of administration.
The scalp area that lies immediately posterior to the front and extends to the vertex (crown). It is bound laterally by the temporal/parietal fringes.
Schematic drawings illustrating the three major anatomically defined recipient zones of the balding scalp.
Miniaturization is the progressive transformation of terminal hair follicles into intermediate and then to vellus hair follicles, which are actually pseudo-vellus, due to the effects of androgens on genetically predisposed individuals.
Paradoxical action of androgens in different body areas. After puberty, androgens will stimulate the gradual transformation of vellus hair follicles, producing tiny, colorless hairs into terminal, thick, long, and heavily pigmented hairs (upper row). In complete contrast, androgens may cause miniaturization of hair follicles on specific areas of the scalp in genetically susceptible individuals causing the reverse transformation of terminal follicles to pseudo-vellus ones and AGA (lower row).
A graft containing three or four hairs (small mini-graft) or five or six hairs (large mini-graft). There are many variations of mini-grafts derived from round grafts. These grafts contained parts of adjacent follicular units and unnecessary tissue which made the grafts larger and more pluggy.
Micrografts were mostly partial FUs, and minigrafts contained multiple FUs or multiple partial FUs.
Minoxidil was initially developed as a potent antihypertensive, but due to the adverse hypertrichotic effect it had on most patients, it soon became the first compound prescribed to grow hair, used as Minoxidil Topical Solution, MTS. Minoxidil is a KATP channel-opener, however, the exact hair growth stimulating mechanisms remain not fully clarified, yet, it is not related to local vasodilation and is more likely associated with the increase in prostaglandin PGE-2 production in the dermal papilla. Minoxidil increases the size and diameter of AGA-miniaturized hair follicles, gradually converts them into terminal ones, stimulates telogen follicles to enter into anagen, increases the duration of anagen, and decreases the duration of kenogen but does not shorten telogen. The efficacy of 5% MTS is concentration-dependent and consistently superior to 2% MTS. It stabilizes hair loss in 85% of patients, 65% of which report new hair growth, and 30% experience significant hair growth, starting at 8 weeks and reaching a plateau at approximately 12 months.
Hair transplantation using multi-unit grafts. In practice, these grafts may be placed into small round holes, slots, or slits.
Grafts that contain two or more follicular units in a single graft. This term replaces the older mini-graft. In practice today, MUGs contain 2-6 follicular units per graft.
The superior border of the occipital area of permanent hair that surrounds the alopecic or thinning vertex.
The rotation of the punch back and forth through different arcs and repetitions per minute (RPMs) during penetration. This may be done by hand or automatically.
The outermost layer of the hair follicle. It merges proximally with the inter-follicular epidermis and distally with the hair bulb.
The superior border of the permanent parietal area of hair that extends posteriorly from a line drawn vertically between the tragus and the beginning of the occipital fringe.
The entire process of harvesting a fraction of a follicular unit so that one portion of the follicular unit is harvested from the donor area while the other portion of the follicular unit remains in the donor area.
The pilosebaceous unit is a complex mini-organ consisting of three anatomic components: hair follicle, sebaceous gland, and arrector pili muscle. The proportions of these components vary among the different types of hair follicles.
An inactive substance prescribed as if it were an effective dose of a needed medication.
A physical or emotional change occurring after a substance is taken or administered that is not the result of any special property of the substance.
Platelet-rich plasma (PRP) is defined as an autologous supraphysiological concentration of human platelets in a small volume of plasma. It has five- to sevenfold times the platelet concentration of normal blood so that platelets can release growth factors (GFs) in large amounts from dense and alpha granules. PRP actions are based on the infusion of elevated concentrations of these GFs, thereby—theoretically— enhancing the healing capacity and tissue generation in the wound bed. Some hair transplant surgeons have used PRP in hair transplantation procedures either by storing the grafts in PRP until they are placed on the scalp or by injecting PRP into the scalp prior to placement of grafts. The level of evidence of various studies of PRP in AGA is low to medium, and even though most studies report positive results in both mild to moderate AGA/FPHL, a large number of questions remain unanswered, such as candidacy, standardization, preparation and delivery of PRP, dosing parameters, frequency, long-term results and synergy with other treatments.
The removal of one or more terminal hairs by pulling out a follicular group with forceps and intending to remove viable follicles from the donor area that can be ed in the recipient area.
Refers to a group of rare, idiopathic, inflammatory scalp disorders that result in permanent hair loss. Cicatricial alopecias are traditionally classified by their inflammatory infiltrate (lymphocytic, neutrophilic, mixed). The inflammatory process affects mainly the upper portion of the follicle and is followed by a permanent destruction of the hair follicle. Primary cicatricial alopecia frequently starts on the central and parietal scalp before progressing to other sites of the scalp. A lack of follicular ostia is the hallmark of scaring alopecia. Crucial to the diagnosis if cicatricial alopecia is a detailed clinical history and one or two biopsy samples of an active lesion. The goal of any scalp reduction surgery are possible once the lesions are burnt out and stable. Graft survival may not be as good as in androgenetic alopecia and disease reactivation is possible at any time after surgery.
Potent bioactive lipid messengers. They cause many physiological responses.
A chronic asymptomatic primary cicatricial alopecia most often involving the vertex. It is non-inflammatory. The classic appearance of pseudopelade is the so-called footprints in the snow. Potent corticosteroids, hydroxy-chloroquine, and thalidomide have all been used.
The “Hair Pull Test“(HPT) is based on the concept of “gentle” pulling of the hair to investigate the shedding of telogen or pathological anagen hairs. The HPT is an easy and straightforward method used to roughly estimate the ongoing severity and activity of any kind of hair loss, regardless of etiology. Mostly it allows determining whether a patient is experiencing an active stage of hair loss. However, it has low sensitivity and null specificity. The HPT is positive in almost every type of hair loss: anagen effluvium, telogen effluvium, loose anagen syndrome, early cases of AGA/FPHL, even in alopecia areata. However, a negative HPT does not necessarily exclude any diagnosis, not even the diagnosis of hair loss itself. Results can vary depending upon when the hair was last shampooed and combed.
The anterior traction used for the removal of the graft after it has been punched. Grafts may be pulled by a one-hand pull with single forceps, a two-hand pull with two forceps or with suction.
A surgical instrument used to obtain small samples of tissue.
An area where hair loss has occurred and hair follicles will be implanted during a hair transplant procedure. Site creation instruments are either standard disposable hypodermic needles (18G–21G) or custom-cut disposable microblades—0.6–1.2 mm wide and 0.23 mm thick—with a chisel or tipped cutting edge and adjustable length to match the different sizes of grafts. Micropunches are not popular.
Refers to the influence of the recipient site scalp on the growth of transplanted hairs. The recipient area will affect certain hair features, such as growth rate, anagen duration, pigmentation, and survival rate, while it did not affect hair caliber.
The enzyme that converts testosterone to the potent androgen dihydrotestosterone (DHT). The 5α-R enzyme reduces the unsaturated bond in the 4 to 5 position of the testosterone molecule to form DHT. It exists as three isozymes whose tissue distribution varies.
A term that refers to rotation followed by oscillation employed during the penetration of the punch. Rotational speed, arc of rotation, ramp (amplitude from starting position to ending position) of rotation, ramp of arc, and duration of each individual cycle may be controlled.
A procedure whereby the punch is rotated a full repetitive 360-degree cycle during the penetration of the skin. This is usually done by automatically.
Incisions made parallel to the direction of hair growth
Schematic of sagittal vs. coronal incisions. Hair direction is also represented with blue arrows. The right side shows coronal incisions made at right angles to the direction of hair growth. The left side demonstrates that sagittal incisions made parallel to the direction of growth.
The over-the-counter Saw Palmetto liposterolic extract contains high amounts of free fatty acids with in-vitro anti-androgenic and 5α-Reductase inhibitory properties. The mild anti-androgenic actions of Saw Palmetto have been documented only in vitro, and there is no convincing evidence that any of these mechanisms are relevant in vivo.
A procedure that is implemented when there is diagnostic uncertainty and when therapeutic options will be altered by an accurate diagnosis. Scalp conditions that usually require biopsy include all forms of scarring alopecia.
Scalp micropigmentation (SMP) is a novel modality of placing a stippled pattern of tattoo dots on the scalp, imitating stubbles of a shaved scalp and giving the illusion of a permanent shading/coverage. These stubbles can also reduce the contrast between scalp skin and hair in areas with thinning or complete baldness, thus efficiently camouflaging lost hair and concealing scalp scars from previous HRS or other etiology.
Scalp reduction involves the excision of bald scalp areas, pulling up the surrounding regions of hair growth, and stitching together the wound edges, aiming to gradually cover the whole scalp with hairy parts. Scalp reductions were very destructive for the scalp tissue, had enormous disadvantages, and caused intense pain and frequent postoperative complications. Moreover, due to stretch back, >40% of the removed surface would re-appear bald during the first 12 weeks, the final shape of the remaining bald surface was unnatural, and the unsightly vertical scars of the operations could not be covered by existing hair. Scalp reduction should not be performed in any case of AGA, but only in cases of repair HRS (to remove wide donor scars) or in cases of scalp reconstructive surgery due to burns, injuries, and tumor removal.
Various alopecia reduction incisions and designs
A superficial cutting of the epidermis and dermis with a punch to produce a superficial circumferential or semicircle incision around a follicular grouping.
The sebaceous gland is a holocrine gland of the skin and almost always accompanies a hair follicle, vellus, or terminal, and the resulting complex is called pilosebaceous unit.
An inflammatory condition of the skin that most commonly occurs on the scalp, face, and chest. The term dandruff or pityriasis capitis corresponds to a milder form of seborrheic dermatitis that is thought to result from a combination of factors. Clinical features can range from fine scaling of the scalp to erythematous patches. It is a relapsing condition that may require maintenance treatment. Anti-dandruff shampoos are readily available and effective in most cases. Common active ingredients include selenium sulfide, zinc pyrithione, ketoconazole, miconazole, and ciclopirox. Tar-based shampoos are also effective.
Senescent alopecia (SA) or senile alopecia, evolved as a concept from clinical observations that diffuse hair thinning involving the entire scalp may develop after the age of 50 in individuals with no family history of AGA. SA is defined as the non-androgen-dependent hair loss or thinning found in individuals >60 years old involving the entire scalp.
Sentinel hairs refer to the very fine single hairs that scattered in front of the hairline to soften the appearance of the hairline.
This is when a sharp punch is ed along the course of the follicle to facilitate its extraction.
The creation of slits over the recipient area. Every recipient site is a three-dimensional puncture and can vary in volume, size, shape, width, depth, angulation, direction, and orientation. The lower the total volume of each site, the lesser the injury and the resulting microscar that will develop, and the more favorable the conditions will be for grafts to grow.
Mixing sagittal and coronal incisions is a common practice. Sagittal incisions are preferred on the hairline’s transition zone and in areas with pre-existing hair (red rectangle), since coronal incisions can cause follicular transection. In all other regions, coronal incisions are preferred (blue circle).
Hair obtained from a donor site directly or sectioned from a larger round graft is ed into a slit made in the scalp by the tip of a scalpel blade.
Dividing the donor strip into sections of variable widths according to the desired graft size called as slivering. The slivering technique has been compared to slicing a loaf of bread, an analogy in which the loaf is the strip and the emerging slices are the slivers. Creating the ideal sliver without transection is the most difficult step in graft preparation. The use of magnification equipment is essential for the creation of slivers.
Spironolactone is a potassium-sparing diuretic with antiandrogenic effects since it decreases Testosterone levels, competitively blocks the androgen receptor, and reduces DHT effects in target tissues. Spironolactone is the most widely used antiandrogen in Dermatology in the USA, primarily used in female acne and as a first-line antiandrogen in hirsutism. It is more rarely used in FPHL, though it does not have any indication in men with AGA due to the potential for feminization. The moderate hair growth potential of Spironolactone is apparent only in high doses, and even though it is generally tolerable, it is not favored by patients since adverse effects are common.
The divergence of follicles from one another that typically occurs at the lower one-third of the follicular unit.
The action of separating a portion of the follicles from a group (follicular family or follicular unit) with the punch in vivo (or in situ).
Cells that reside in rather undifferentiated, quiescent states and form precursors, transient amplifying cells, that provide further proliferation and differentiation into the different cell types. Hair follicle stem cells are multi-potent, capable of proliferation and able to give rise to all cell types of the hair, the epidermis and the sebaceous gland.
A technique for harvesting donor hair that involves the excising of a ellipsoid horizontal section of safe donor hair from the occipital, parietal and occasionally temporal regions. The resulting wound is sutured or stapled and leaves a linear scar. Further splitting of the strip graft into smaller grafts, namely minigrafts and micrografts was initially done and later, intact, naturally-occurring FUs were and still are, isolated.
The border of hair that extends from the fronto-temporal point to a point that lies straight up from the external ear meatus.
Telogen is the phase during which the hair follicle “rests”, since the proliferation and growth of hair cells ceases. In Telogen, the hair follicle remains mostly inactive, hair growth is suspended, and nuclear activity discontinues. The hair follicle continues to be metabolically active, and some early signs of the new hair follicle emerging from its base can be seen.
Refers to the excessive loss of telogen hairs due to an abnormality in hair cycling. It may occur in response to a number of triggers including fever, hemorrhage, severe illness, stress, childbirth, crash dieting and iron deficiency. It typically occurs approximately 3 months from the time of the precipitating event.
Refers to the two upper outer corners where the forehead meets the hairline. This is usually the first area where male pattern baldness is observed, causing the hairline to recede.
Terminal hair follicles (>60 μm diameter; >2 mm length) appear mostly on the scalp and face. Terminal hairs usually have a medulla and are heavily pigmented. Terminal hair follicles anchor deep into the skin (2.558–3.865 mm) and have a bell-shaped, highly distinctive bulb.
A term used to describe the attachment of the connective tissue sheath and outer root sheath to the surrounding adipose of a follicle.
A condition caused by a dermatophyte infection of the hair follicle. It can be inflammatory or non-inflammatory.
A reconstructive balloon-like device that can be used to enlarge the hair-bearing scalp on the sides of the head, providing a larger supply of hair with which to replace the bald areas. Expertise in the surgical anatomy of the scalp, correct expander choice and placement, meticulous subgaleal undermining, proper galeotomies, and long-term care of patients were all equally necessary. Older techniques of scalp reduction and tissue expansion, excision of many large scarring defects can be accomplished, such as correction of burns, injuries, removal of scalp tumors, and management of scarring alopecias.
An internal device used to stretch the scalp attached with hooks under the galea of the hair-bearing area. Internal dilators, such as the Frechet extender and Silastic suture or custom-made extenders require two procedures. After conventional Alopecia reduction is performed, the extender is attached with hooks under the galea of the hair-bearing area. Then, it is stretched to 100% of its size and hooked to the galea’s undersurface on the contralateral side. The wound is then closed, and the extender is left in place for 30–40 days. The second surgery involves the removal of the extender and undermining, just as during standard AR. The bald area is excised, and the wound is closed.
Keratin-based fibers that adhere to the scalp and existing hair. They help thicken the appearance of existing hair and camouflage the balding areas on the scalp. Toppik Hair Building Fiber magnetizes the hair with static electricity and will stay in place until the following shampoo.
A condition that is caused by excessive stretching of the hair shafts through hair-styling practices. Thinning and recession involve the frontal area but may extend into the temporal regions. Prolonged traction alopecia can scar the new hair follicle and cause permanent hair loss. Hair transplantation is successful in lowering the receded frontal hairline and re-establishing the appropriate density.
A relatively uncommon condition usually detected in early childhood. Hair loss presents itself near the frontotemporal point, in a triangular pattern, with the base of the triangle directed anteriorly. The area may be entirely hairless or have small vellus hairs scattered throughout. Triangular alopecia is amenable to hair transplantation and excellent cosmetic results can be achieved.
The trichophytic closure is a sophisticated closure technique employed to decrease the “show-through” of the donor scar between the hair of the SDA; it allows hair to grow through the scar while the wound heals adding to the camouflage, thus rendering the scar almost inconspicuous.
A dermatoscopy of the hair and scalp. It can be performed with a handheld dermatoscope or a digital videodermatoscopy system. It may be applied in the differential diagnosis of multiple hair and scalp diseases.
This refers to the removal of the dermis and other undesired perifollicular tissues of a graft under the microscope with the aim of slimming the graft.
A simple clinical test that is used to show hair fiber fragility. With one hand, a group of hairs is held while the other hand pulls away the distal ends. Any hair breakage is considered abnormal and is a sign of hair fragility.
An ancillary technique used to minimize follicular transection during strip harvesting by infiltrating the skin subcutaneously with large amounts of normal saline, often containing diluted lidocaine and epinephrine. The injection of this solution causes an artificial swelling of the area, temporarily increasing the distance between FUs and increasing their exit angle, making hair more vertical, thus allowing less transection. Furthermore, the nerves and blood vessels are cushioned from the surgical incision, and the induced swelling caused vasoconstriction through increased hydrostatic pressure, which enhanced hemostasis.
Vellus hairs (<30 μm diameter; <2 mm length) constitute the second type of hair produced by the hair follicle and continue to grow throughout life. They are silky, unmedullated, mostly unpigmented. Vellus hair follicles are the most prominent hair follicle type in the postnatal period, actually representing the miniaturized remnants of terminal hair follicles that comprised the actual coat of hair that our primate ancestors used to have.
The vertex and crown are the most posterior area of the Norwood stage III vertex or greater stages. Although the terms “vertex” and “crown” are very often used interchangeably, they are different regions of the scalp, defined as follows: Vertex is the caudal part of the top of the scalp, anterior to the crown, where the hair still points in a forward direction. Crown is the convex area where the occipital and parietal areas join, and the hair takes a swirling pattern. The natural crown can be conceptually divided into four parts: the center of the whorl, the upper arc, the lower arch, and the vertex transition point.
The VTP corresponds to the midline point where the midscalp horizontal plane gradually shifts to the vertex's vertical plane. The VTP lies immediately posterior to the skull's highest point and approximately where the hair changes from an anterior direction to a whorl arrangement. The VTP is a reference point of high cosmetic significance in HRS. Transplanting as far posteriorly as the VTP is adequate to give the appearance of a full head of hair to individuals classified as stage VI–VII when viewed frontally or frontolaterally. However, one should consider that the location of VTP is inherently subjective since there are several varieties of head shapes and contours.
The circular spiral pattern that exists in the vertex. A whorl pattern of hair direction characterizes the normal crown area. The crown whorl has been considered as an inherited feature.
The clockwise whorl pattern (S pattern) corresponds to 75% of patients, while the counter-clockwise whorl pattern (Ζ pattern) corresponds to 11%. Double whorls are very rare (SZ pattern, 3.2%, and SS pattern, 0.6%), while a “diffusion pattern” occurred in 9.8% of the individuals, mainly African-Americans and females.
Crucial to enzyme functioning. Zinc deficiency is also associated with alopecia.