Outcome of Follicular Unit Extraction in Cicatricial Alopecia

INTRODUCTION
Cicatricial alopecia refers to a group of disorders
that destroy hair follicles which are replaced with
scarred tissue, causing permanent hair loss [1].
Cicatricial alopecias are subdivided into two groups
“primary” and “secondary” [2]. Primary cicatricial
alopecia includes various groups of inflammatory
conditions with unknown etiology. They lead to
pathological replacement of the follicular structures
with fibrous tissue and consequently permanent
159
loss of hair shafts [3] e.g. lymphocytic, neutrophilic
and mixed types. Secondary cicatricial alopecia
could result from skin inflammatory conditions or
from any physical trauma that damages to the skin
its appendages e.g. trauma, burns, radiation induced
and infections [1]. There are many strategies for
management of 2ry cicatricial alopecia, which
differ with the location, size and other scarred area
characteristics [4]. These strategies include excision
of the affected area to be closed primarily, by using
a flap or using tissue expansion in large scars
followed by reconstruction of the defect, or to use
hair transplantation either alone or combined with
scar reduction [1]. Hair transplantation has gained
popularity [1] as a permanent method for restoring
hair loss [5]. It could be used for scar camouflage
in the hair bearing areas and could provide restoration
not obtainable with other methods, and that
could change the lives of patients and restore them
to the premorbid condition [6]. These approaches
include Follicular Unit Transplantation (FUT)
technique was reported first within 1995 [7]. The
large drawback regarding that harvesting technique
was the subsequent linear donor scar [8]. Another
approach is the Follicular Unit Extraction (FUE)
technique, which was first introduced by Rassman
and Bernstein with the benefit of absence of a
linear scar and rapid recovery of the donor area
[9]. In cicatricial alopecia cases, hair transplant is
considered challenging because of the degenerative
changes and decreased vascularity of these areas
that may produce a lower survival rate of donor
hair [10]. The condition has to be stationary before
considering hair transplantation in cicatricial alopecia
cases [1], so that; a minimal waiting period
of 4 to 6 months is recommended, to be assured
that the scar is mature and there will be no further
hair growth [6]. The efficiency of PRP as an adjuvant
therapy combined with hair transplantation
had been discussed in many studies. Li, Choi et
al. (2012) had reported that PRP injection played
an important role in improving cutaneous ischemic
conditions and increasing vascular structures around
hair follicles [11]. PRP was used as an adjuvant to
be injected intradermally into the recipient area
just prior to graft implantation, resulting in a better
outcome of hair transplant with scar quality improvement
in a case of cicatricial lichen planus of
the scalp [10]. Nanofat injection was mentioned in
the literature and practiced as a skin rejuvenating
maneuver and a useful way for scar maturation
and improvement due to its small size and the fact
that it contains stem cells [12]. Using of nanofat in
improving hair follicle survival after hair transplantation
was mentioned by Barr and Barrera
(2011), they have noted that the use of fat grafting
before the placement of hair follicles assist in
proper placement and optimal growth of the grafts
in this attenuated tissue [6]. Akdag, Evin et al.
(2017) reported the usage of FUE hair transplantation
combined with autologous fat grafting for
camouflaging of cleft lip scar resulting in better
graft survival rate and high level of patient satisfaction
[13].
This study aims to evaluate the role of PRP and
nanofat injections together with follicular unit
extraction hair transplantation technique for restoration
of hair in secondary cicatricial alopecia.
PATIENTS AND METHODS
This prospective clinical study was conducted
in Mansoura University Hospitals, Plastic and Burn
Surgery Department in the period between March
2016 to March 2017. 30 patients with secondary
cicatricial alopecia were included in the study.
Inclusion criteria: All patients with secondary
cicatricial alopecia of both sexes with age between
15 to 50 years.
Exclusion criteria: Those with 1ry cicatricial
alopecia, recent 2ry cicatricial alopecia less than
6 months (immature scar), patients with unrealistic
expectations, patients with chronic diseases e.g.
hepatic or renal or using systemic chemotherapy,
anticoagulation therapy, or steroids, patients with
blood disorders and platelet abnormalities, and
those with systemic diseases including hemodynamic
instability and sepsis.
Patients were randomized using envelop method
into three groups, where each group contains 10
patients as follow:
- Group A: Patients received local intradermal PRP
injections one week before hair transplantation
followed by two injections 2 and 4 weeks postoperatively.
160 Vol. 44, No. 1 / Outcome of Follicular Unit Extraction in Cicatricial Alopecia
- Group B: Patients received local intradermal
nanofat injections one week before hair transplantation
followed by two injections 2 and 4
weeks postoperatively.
- Group C (Control group): Patients underwent
hair transplantation only without any kind of
local injections.
Follicular unit extraction procedure:
1- Preparation of the donor area and graft harvesting:
Patients’ hair was cut to 1-2mm. The patient
was placed sitting with head flexed to a comfortable
position adjusted by the patient himself. Under
complete aseptic condition, occipital and postauricular
nerve blockage was obtained with 0.25%
bupivacaine hydrochloride. Infiltration anesthesia
was done with a solution containing 70ml normal
saline 0.9%, 30ml of 0.5% lidocaine hydrochloride
and 1ml of adrenalin (1mg/ml). After waiting for
the adrenaline action, graft harvesting was started
with the help of 2.5 x magnification, and using a
micro motor that works at 1500-3000 rpm, with
the micro punch chosen ranging from 0.8 to 1mm
attached to the hand piece. Grafts were mainly
taken from the occipital scalp, while thin supra
auricular and temporal hair was used to a lesser
extent to mimic the natural appearance of hair.
Punch size was chosen ranging from 0.8 to 1mm
based on follicular unit density. The released grafts
were collected manually using an extraction
jeweler’s forceps. The grafts were then aligned
into five rows, with ten grafts in each row (a total
of 50 grafts) on a piece of wet gauze over a cold
saline (Fig. 1). Graft harvesting was continued till
an adequate number of healthy follicles had been
reached. On completing the harvesting step, occipital
and postauricular nerves were reblocked to
minimize the expected pain in the donor area during
the transplantation process. Dressing of the donor
area was done with sterile gauze, and the patient
was turned supine. The donor area is shown in Fig.
(2).
2- Preparation of the recipient area and graft
insertion:
The recipient area was marked, and the same
infiltration anesthesia used in the donor area was
performed. Then the recipient site was prepared
using micro slits of different sizes varying from 1
to 1.3mm taking into account the natural hair angles
to gain the most natural looking results. Grafts
were placed using an implantation jeweler’s forceps
with a density of 20-30 follicular unit (FU) per
cm2.
Egypt, J. Plast. Reconstr. Surg., January 2020 161
Post-operative measures:
Non-adhesive dressing with antibiotic ointment
was used to close the donor area with placement
of compression bandage. This dressing to be removed
on the postoperative 5th day. No dressing
was applied to the transplanted area. All patients
were instructed to keep it way from any type of
contact that may cause hair displacement or fall
also to keep the transplanted hair as moist as
possible for at least the first 5 days with the use
of normal saline 0.9% in the form of spray. Postoperative
antibiotic, analgesics and drugs were
prescribed for all patients.
Post-operative follow-up and evaluation:
1- Manual counting of the transplanted follicular
units per cm square using a trichoscope (Dermlite
2 Pro HR Dermatoscope), Immediate on
transplantation (Fig. 3) to be compared with
the counting after the follow-up period (Figs.
4,5).
2- Digital photography and blind study:
Serial photographs were taken pre-operatively
and 6 months post-operative for our patients, and
they were evaluated by three plastic surgeons, who
were blinded to the type of procedure, and then
Fig. (1): Grafts were aligned in five rows, with 10 grafts in
each row.
Fig. (2): The donor area, the grafts were collected.
Fig. (3): Trichoscopic shot immediate on transplantation 10x. Fig. (4): Trichoscopic shot 6 months after two sessions of
hair transplantation 10x (nano fat group).
their average evaluation was calculated and performed
using the specific scale based on heir
growth as follow:
• No change (No growth of hair) = zero points.
• Mild to moderate improvement (Hair growth
but still close to the pre-operative picture) =
one point.
• Significant improvement (Hair growth close
to the surrounding hair bearing are) = two
points.
3- Patient satisfaction:
- Measurement of patient’s degree of satisfaction
with a scale from 0 to 4 points, where 4 means
highly satisfied patient, 3 means moderately satisfied
patient, 2 means mild satisfaction, 1 means
unsatisfied and 0 means highly unsatisfied. It’s
based on the following questions, each for a point:
• Camouflage; camouflaged or not.
• Hair density; it became more dense or not.
• Intraoperative comfort; patient felt comfort
during the operation or not.
• Wish to reoperate other scar site, or not.
- Assessment of patient satisfaction was done
within 6-8 months after hair transplantation.
162 Vol. 44, No. 1 / Outcome of Follicular Unit Extraction in Cicatricial Alopecia
Fig. (5): Trichoscopic shot after the follow-up
period with two sessions of hair transplantation
10x (PRP group).
Fig. (6): Fifty years old male with post traumatic alopecia of his left
eyebrow. Patient underwent hair transplantation together with
PRP injection. (A) Preoperative photo. (B) Eight months postoperative
photo.
Fig. (7): Twenty seven years old male with post traumatic alopecia of his moustache, patient underwent hair
transplantation together with nano fat injection. (A) Pre operative photo. (B) 12 months post operative.
Fig. (8): Twenty six years old male with post traumatic alopecia over the left side of his beard, patient underwent
hair transplantation alone. (A) Pre operative photo. (B) Eleven months post operative photo.
(A) (B)
(A) (B)
(A)
(B)
Egypt, J. Plast. Reconstr. Surg., January 2020 163
RESULTS
This study included 30 patients, 23 were males
and 7 were females. They were divided into 3
groups according to the procedure done: A,B and
C, with 10 patients in each group. The mean age
of patients in group A is 27.40±9.54 years, in group
B 26.20±8.90 years and 24.50±8.36 years in group
C. Eighty percentage of the patients (8 patients)
of group A and B were males and 20% (2 cases)
were females while in group C, 70% of the patients
(7 patients) were males and 30% (3 cases) were
females. Trauma was the cause of cicatricial alopecia
in 50% of the patients of group A (five
patients), 90% of group B (nine patients) and 70%
of group C (seven patients) while burn was the
cause in 20% of the patients of group A (two cases),
10% of group B (one case) and 20% of group C
(two cases). Ten percentage of the patients of both
group A and C (one case for each) developed
cicatricial alopecia after a cleft lip repair surgery
while 20% (two cases) of group A after a neurosurgical
operation. The mean time elapsed between
trauma and surgery was 9.85±8.89 years for group
A, 4.90±3.60 years for group B and 9.40±9.87
years for group C. The mean hair growth for group
A was 83.76±7.06% after the follow-up period,
84.73±8.4 for group B and 83.70±3.29 for group
C (Table 1). The mean of blind study for group A
was 1.60±0.35, 1.53±0.32 for group B and 1.43±
0.32 for group C (Table 2). The mean follow-up
period for group A was 8.80±1.93 months, 8.60±
1.65 for group B and 8.20±1.93 for group C. The
mean count of transplanted FU was 28.50±245.22
for group A, 123.00±94.64 for group B and 127.00±
87.28 for group C. No significant difference between
levels of satisfaction among patient in all
groups as shown in (Table 3).
DISCUSSION
The current study included cases of secondary
cicatricial alopecia that resulted from nonfollicular
diseases that cause follicular destruction, e.g., from
trauma, burn, or infection [14]. Many strategies
were tried to repair that condition, including hair
transplantation that has gained popularity in the
recent years [1] as a permanent method to restore
hair loss [5]. Kutlubay, Murat et al. (2013) decided
that the condition must be stationary before considering
hair restoration process in cases of cicatricial
alopecia to make sure that blood supply is
sufficient to nourish the hair graft [1], also Pathomvanich
and Imagawa (2012) reported that a minimal
waiting period of 4 to 6 months is recommended,
to be assured that the scar is mature and there will
be no further hair growth [14]. In the current study,
the minimum waiting period was 1 year. Any patients
with recent history of trauma induced aloppecia
less than 6 months were excluded. The whole
procedures in the current study were done under
local anesthesia, this was accomplished with help
of the good compliance of the age group population
selected for this study with the mean age
27.40±9.54 years, 26.20±8.90 years and 24.50±8.36
years for the groups A, B and C respectively. Most
of cases included in this study were males, accounting
for 80% of both groups A and B, and for 70%
of group C. That could be explained to the more
aggressive life style and incidence of traumas in
males compared to females. Barr and Barrera
advised to limit the use of epinephrine in the
cicatrized recipient bed during its preparation prior
hair grafts insertion [6]. Also Kutlubay, Murat et
al., recommended that epinephrine concentration
to be used in recipient preparation should be minimized
than that used in the donor area preparation
(1/200.000) as it may decrease the blood supply
and therefore graft survival [1]. In a single case
study of hair transplantation for cicatricial alopecia,
Saxena, et al., haven’t used adrenaline for anesthesia
or tumescent fluid in both donor and recipient
[10]. In the current study, the same adrenaline’s
concentration for donor area preparation was used
for preparing the recipient cicatrized area
(1:100000). That would keep the benefit of
adrenaline’s hemostatic effect in good visualizing
of the slit sites prepared and adjusting the required
hair angle during insertion. Using adrenaline in
both donor and recipient sites in the current study
showed no evidence of impaired vascularity or
impaired hair growth. In the current study more
tumescent fluid was infiltrated to the donor areas
immediately before using the micro punches to
maintain the tumescent effect of the fluid and
maintain the hair follicle position, thus reducing
Table (1): Survival rate of all groups.
Hair growth
(%)
83.76±
7.06
Group A
(N=10)
84.73±
8.4
Group B
(N=10)
83.70±
3.29
Group C
(N=10)
0.07
6
F
0.92
7
p
Table (2): The mean of blind study average of all groups.
Blind study
average
1.60±
0.35
Group A
(N=10)
1.53±
0.32
Group B
(N=10)
1.43±
0.32
Group C
(N=10)
0.65
3
F
0.52
9
p
Table (3): Patient satisfaction for all groups.
Patient satifaction:
I (Unsatisfied)
II (Mild)
III (Moderate)
IV (Highy satisfied)
Group A Group B Group C
1.3
04
c2
0.9
71
p
1342
No.
10
30
40
20
%
1423
No.
10
40
20
30
%
2521
No.
20
50
20
10
%
rate of follicle transection. On harvesting large
graft numbers, we have noticed that the hemostatic
adrenaline effect together with the supporting effect
of the injected tumescent anesthesia will be lost
with time. So it’s recommended to reinfiltrate the
donor area with a tumescent fluid containing adrenaline
(1:100000) with progress of time. To our
knowledge this additional step was not recommended
by any study concerning FUE harvesting. Recommendations
for the optimal site of graft harvesting
varied in the literature as Jung, Oh et al.,
experienced a study of hair follicle transplantation
on scar tissue of 25 cases where most of graft
harvesting was obtained from the occipital and
posterior auricular areas [15]. Kutlubay, et al., also
stated that the recommended areas for graft harvesting
were the occipital, parietal, and posterior
temporal regions [1]. Bicknell, et al., recommended
using the occipital scalp with a lesser extent the
temporal and supra auricular regions as a donor
areas [16]. Ors, et al., stated that the occipital region
is the easiest area for graft harvesting [17]. In the
current study we used the occipital scalp as a donor
area for most cases where accessibility with less
transection rate were noticed, while temporal and
thin supra auricular hair were used for a lesser
extent to mimic the natural appearance of areas
with normally thinner hair growth. Density of the
transplanted follicular units per cm2 varied in the
literature, Pathomvanich and Imagawa (2010)
recommended to transplant at a density of 20
FU/cm2 for the scaring tissue because of the limited
vascular supply of these areas [14]. Barr and Barrera
stated that a density of 20 to 30 grafts per cm2 is
reasonable when approaching a scarred tissue bed
[6]. Kutlubay, et al., advised to transplant as much
as 15-20 FU/cm2 in regions with less blood supply,
they agreed with previous studies that it is generally
safe to increase the concentration of follicles to as
high as 20-30 FU/cm2 for the regions with better
perfusion [1]. However a density of only 18 units/
cm2 was utilized and recommended by Saxena, et
al. [10]. In this current study we have agreed with
consensus in the literature regarding FUE density
used in cicatricial aloppecia cases and a density
of 20 to 30 FU per cm2 was applied, variations
with this range was only applied in limited cases
to mimic the patients natural hair pattern. The
current study showed an average survival rate of
83.76%, 84.72% and 83.7% of the transplanted
follicular grafts for groups A,B and C respectively
which is consistent with the literature. As Saxena
et al., in their single case study and follow-up
period of 10 months reported that 80% of the
transplanted grafts have survived and showed
optimal growth after use of PRP injection together
164 Vol. 44, No. 1 / Outcome of Follicular Unit Extraction in Cicatricial Alopecia
with a hair transplantation in a case of scalp cicatricial
alopecia [10]. The current study result agreed
with Akdag, et al., who conducted a study on 20
patients having alopecic scar in the cleft lip area
where autologous fat injection was done along
with FUE hair transplantation showing that the
average survival rate was 82% [13]. Counting of
the transplanted follicular units immediately post
operatively and after the follow-up period was
done in this study with the help of the magnification
power of Dermlite 2 Pro HR Dermatoscope. Many
studies had discussed the efficiency of PRP as an
adjuvant therapy combined with hair transplantation
in enhancing the results of FUE. Uebel, et al., used
PRP therapy along with hair transplant in male
hair pattern baldness where follicular grafts were
kept in PRP for 15 minutes before implantation.
They found a considerably significant effect of
platelet growth factors on the yield of follicular
units over non PRP used conventional hair transplants
[18]. Li, et al., had reported that PRP injection
played an important role in improving cutaneous
ischemic conditions and increasing vascular structures
around hair follicles [11]. PRP was used as
an adjuvant to be injected intradermally into the
recipient area just prior to graft implantation,
resulting in a successful hair transplant outcome
in a case of cicatricial lichen planus of the scalp,
in the same study, it has been observed that the
quality of scarred tissue was improved after transplant
[10]. Garg reported that PRP injection immediately
after creating slits over the recipient area
is beneficial in giving faster density, reducing the
catagen loss of transplanted hair, recovering the
skin faster and activating dormant follicles in FUE
transplant subjects with androgenic alopecia [22].
In the current study PRP was injected intradermally
one week before hair transplantation followed by
two injections at 2 and 4 weeks after the operation.
Our findings in this current study showed some
improvement comparing PRP group with the conventional
group (group C). However, the improvement
in the percentage of hair follicle growth was
not statistically significant, so we can conclude
that PRP is a beneficial addition to the FUE procedures
in cicatricial alopecia but cannot be considered
as an essential step regardless documented
improvement in results with PRP injection in the
literature. Nanofat injection was mentioned in the
literature and practiced as a skin rejuvenating
maneuver and a useful way for scar maturation
and improvement. Tonnard et al., has used nanofat
grafting for skin rejuvenation purposes due to its
small size and the fact that it contains stem cells
[12]. Using of nanofat in improving hair follicle
survival after hair transplantation was mentioned
Egypt, J. Plast. Reconstr. Surg., January 2020 165
by Barr and Barrera, they have noted that the use
of fat grafting before the placement of hair follicles
may assist in proper placement and optimal growth
of the grafts in this attenuated tissue [6]. Kemalog
˘lu had reported the use of nanofat grafting under
a split-thickness skin graft which resulted in better
outcomes with increase in the graft take, these
results were explained to be caused by presence
of stem cells that stimulate the collagen and endothelial
cells which promote angiogenesis and
that was important in the graft healing process [23].
Akdag, Evin et al., reported the usage of FUE hair
transplantation combined with autologous fat grafting
obtained by using miniliposuction harvesting
cannulas for camouflaging of cleft lip scar, The
study was performed on 20 patients where fat
grafting was done three months before the transplantation
procedure, resulting in better graft survival
rate and high level of patient satisfaction [13].
In the current study autologous nanofat was injected
intradermally one week before hair transplantation
followed by two injections at 2 and 4 weeks after
the operation. Our findings in this study showed
some improvement comparing nanofat group with
the conventional group (group C). However, the
improvement in the percentage of hair follicle
growth was not statistically significant, so we can
conclude that nanofat is a beneficial addition to
the FUE procedures in cicatricial alopecia but
cannot be considered as an essential step regardless
documented improvement in results with nanofat
injection in the literature. The only drawback noted
in the current study regarding usage of nanofat
grafting was the need of using tumescent fluid and
local anesthesia which was considered as a discomfort
to some patients. Many sessions were recommended
in the literature to obtain optimum satisfying
results for patients with cicatricial alopecia,
as stated by Barr and Barrera that one to three
sessions of hair transplantation will be required to
achieve optimal aesthetic results [6]. So it’s important
to explain the possibility of secondary (may
be more) operations to the patient in advance [15].
In the current study we explained the possibility
of multiple sessions to our patients in order to
adjust their expectations also to obtain the best
satisfying and aesthetically accepted results, and
however only one session was included and recorded
in the study for making the outcome of the
procedures statistically coherent. In the current
study we invented a questionnaire based scale to
measure patient’s degree of satisfaction which is
ranged from zero to four points, where 4 points
meant highly satisfied patient, 3 points meant
moderately satisfied patient, 2 points meant mild
satisfaction, one point meant unsatisfied and zero
point meant highly unsatisfied. Our study showed
that there was no significant difference between
the three groups as regards patient satisfaction.
Another scale used in our study by three plastic
surgeons that were blinded to the type of procedure
done and based on hair growth. Each surgeon gave
a score for each case and then their average evaluation
was calculated showing no significant difference
between the three groups as regards hair
growth.
Conclusion:
Secondary cicatricial alopecia is a common
complication following trauma to the hair bearing
areas with a devastating psychological impact on
the patient. To have a successful process; normal
density, direction and distribution of hair in the
alopecic areas are essential to be considered. In
the current study, follicular unit extraction is used
for hair restoration either alone or combined with
platelet rich plasma or nanofat injections. Although
adding PRP or nanofat injections to the FUE procedure
provides an excellent improvement in the
texture and quality of the scarred tissues compared
to other cases underwent without, there are no
significant differences in the clinical outcomes of
hair restoration including hair growth density. It’s
claimed that adding PRP or nanofat to FUE in
managing cases of cicatricial alopecia doesn’t have
an upper hand either in the outcome or in patient
satisfaction. However it still needs further studies,
larger sample of patients and multicentric study to
be proven.