Assessment The Role Of Platelet Rich Plasma In Follicular Unit Extraction Hair Transplantation

INTRODUCTION

Hair is very important in character and personality. Hair shafts are very important in functions like thermoregulation, collection of sensory information, protection against environmental trauma, social communication, and camouflage. Each one of humans displays an estimated total number of 5 million hair follicles (HF), of which 80,000–150,000 are located on the scalp.¹

Hair transplant surgery has made significant advances and improvements over the past 25 years that has resulted in highly satisfied patients.  The movements from mini- and micro-grafting techniques to the now-standard follicular grafting techniques have led to more aesthetically pleasing and natural appearance of transplanted hair. While the strip technique was the most practiced method of donor harvest.²

The final cosmetic outcomes did not depend only on the graft type (single hair on grafts or follicular units). The survival rate of the transplantation and the skills of the surgeon but also on the number of grafts can transplant. Thus, advances towards increasing the number of complete follicular units harvested by reducing the follicular transection rates (FTR) help to achieve the optimum desired result.³

There are many factors beneficial in achieving good results with hair transplantation surgeries; finding the optimal storage solution and the most effective.⁴

Hair growth has an individual cycle. During the first 2 weeks of implantation, the catagen phase occurs, marked by an inflammatory process in which redness in the scalp and shedding of the hair shaft is common. The patient then enters the telogen phase, which lasts between 3 and 4 months. This is followed by the latency period, which precedes the third phase, anagen. During this phase, the future hair begins to grow.⁵

Intra‑operative injection of PRP is beneficial in giving faster density, reducing the catagen loss of transplanted hair, early recovery of the skin, the faster appearance of new anagen hair in FUE hair transplantation.⁶

Cicatricial alopecia areas are poor graft recipients because of reduced blood perfusion in it. The percentage of grafted follicles that survive depends in great measure on the blood supply of the vascular bed. PRP is a rich source of anagen-maintaining factors, such as insulin-like growth factor 1 (IGF-1), basic fibroblast growth factor (bFGF), and vascular endothelial growth factor (VEGF). Injection of PRP has been demonstrated to improve cutaneous ischemic conditions and to increase vascular structures around hair follicles.^7&8

This work aimed to study the effect of Platelet-rich plasma and assess its role in follicular unit extraction hair transplantation.

PATIENTS AND METHODS

This study was done on 40 patients suffering from alopecia and candidate for follicular unit extraction (FUE) hair transplantation, with age between 25 years and 60 years in group androgenic alopecia; with no age limitation in cicatricial alopecia, from  June 2017 to  March 2020 Patients will be divided into two main groups;

Androgenic alopecia, the group I was 20 patients.

Post cicatricial alopecia, Group II was 20 patients.

Every group will be divided into subgroup:

Subgroup (a) 10 patients will be managed by follicular unit extraction hair transplantation,

Subgroup (b) 10 patients will be managed by follicular unit extraction hair transplantation with adding Platelet-Rich Plasma (PRP) injection of 0.1cc for every square centimeter in the recipient scalp with the following regimen; 1  week post-operative; 2 weeks post-operative; 3  weeks post-operative; Then Each month for three consecutive months.

The evaluation was done by analysis of preoperative and postoperative of follicular unit extraction (FUE) hair transplantation and throughout the time of wound healing and complication management if occurred up to 6 months by Patient satisfaction questionnaire, scalp redness, hair density, length, direction & texture by using Trichoscopy in the analysis.

Ethical approval:

An approved was obtained from the Ethical Research Board (ERB) of the Faculty of Medicine, Al-Azhar University, Cairo, Egypt. Before the study proceeding, all patients assigned informed consent after the obvious explanation of the possible adverse events.

Operative Technique

We had used in this study Follicular unit extraction hair transplantation based on micromotor & straight handpiece, Jewelers Micro Forceps (Extraction & implantation), punches of size 0,85mm & needle holder with slits or blade knife no.11 as showed at figures 1, 2, 3 & 4.

Figure (1) Micromotor & Handpeice

Figure (2) Jewelers for extraction and implantation

Figure (3) Punches 

        Figure (4) ,Needle holder & Blade knife No. 11

Preoperative Marking:-

The new hairline as shown at the figure 5. It should be created at a specific distance from the glabella, ranged from 7 to 9 cm from glabella.

Figure (5) Hair line design

Site of donor:-

Back & sides of the scalp as shown at the figure 6.

Figure (6) Donor site  

Anesthesia:-

Local anesthesia with 2% xylocaine concentration & adrenaline 1 mg for both donor and recipient.

Donor site anesthesia

For the ring block, at the donor site, we had prepared a solution of xylocaine 30 ml with the addition of 30 ml normal saline with the concentration of adrenaline (1:1000) for donor & recipient block.

We inject at the posterior hairline for the prober block of the posterior occipital nerve.

Recipient site anesthesia

For ring block at the recipient site, we injected 3 cm on each side & when we are injecting we diffuse it medial and lateral to the supraorbital notch for prober block of both supraorbital and supratrochlear nerve.

To complete the ring block of the recipient site we injected at the hairline at the temporal region for the block of zygomaticotemporal nerve.

Procedure:-

Harvesting of hair grafts

Follicular units harvested by sharp punches we have used in this study 0,85 mm diameter sized punches.

Storage of hair follicle grafts as shown in figure 7. We stored grafts in storage solution (cold saline) put at gauze during procedure time.

Figure (7) Hair grafts

Creation of recipient sites and implantation of hair grafts

Creation of recipient sites and implantation of hair grafts

Creation of the recipient sites in the recipient area with blade width about 1.1 mm or with scalpel knife No. 11 carried on the needle holder.

Insertion of the graft with using of implantation jewelers.

Dressing:-

The dressing was exposed or closed according to site and patient tolerance, the closed dressing was removed from 2-4 days postoperatively.

PRP preparation:- 

Double centrifugation process of PRP as shown at the figure (8),

The sample is initially collected in tubes that contain anticoagulants about 1 ml of sodium citrate for every 10 ml of blood.

 The PRP is obtained from a sample of patients' blood drawn at the time of treatment. A 30 cc venous blood draw will yield 3-5 cc of PRP, a double centrifugation process of PRP, the sample is initially collected in tubes that contain anticoagulants about 1 ml of sodium citrate for every 10 ml of blood.

The first spin step was performed at 2500 rpm for 4 to 5 minutes for separation of whole plasma from RBCs as showed at the figure (8).

For the production of pure PRP (P-PRP), the upper layer and superficial buffy coat are transferred to an empty sterile tube.

The 2nd spin step was performed at 3500 to 4000 rpm for 20 to 25 minutes for sedimentation of buffy coat and creation of PRP.

The upper portion of the volume that is composed mostly of PPP (platelet-poor plasma) is removed. Pellets are homogenized in lower 1/3rd (5 ml of plasma) to create the PRP (Platelet-Rich Plasma).

Figure (8) Centrifuge, tubes & sodium citrate

Figure (10) Front view pre-operative and 6^th months post-operative.

Figure (11) Case 1 Right lateral and Left Lateral views 6^th months post-operative

Figure (12) Case 2 Front view pre-operative and 6^th months post-operative.

Figure (13) Case 2 Basal preoperative and 6^th months post-operative

Figure (14) Case 3 Back view pre-operative and immediate post-operative.

Figure (15) Case 3 the left photo for 3 months post-operative and the right photo for 6^th months post-operative

Figure (16) A- Trichoscope with magnification power (x50) to (x200), B-Trichoscopic image 3 months post-operative for the recipient of androgenic alopecia

RESULTS

Objective and subjective analysis of 40 patients in this study, Time of extraction was ranged from 1 hour to 4 hours according to donor & numbers of graft reacquired to be harvested from the donor.

The total average time of operation was ranged from 2 hours in the post-traumatic or post-burn scar to (6-8) hours in androgenic male pattern alopecia.

Evaluation of density, length, and rate of regrowth was through using Trichoscope & patient satisfaction was through a questionnaire on every follow up during the first 6th months.

The results of this study were evaluated using trichoscopy assessment all over the study. Showed marked improvement with using PRP in patients presented post cicatricial alopecia figures 14 & 15 as showed at diagrammatic figures 19 & 20 and Table 2.

Early good improvement with patient post androgenic alopecia Figures 11, 12 & 13 as shown at diagrammatic figure 17&18 and table 1.

The improvement included in a reduction in post-operative recovery time for wound and soft tissue, Softening of in post cicatricial alopecia; also early increased in density and length is noticed with the group with PRP regimen;

The hair starts with growth in groups with PRP earlier than other groups, with no statistical difference in 6th months.

However, after a long period of follow up for one year, it shows no difference in androgenic alopecia with using PRP or without using PRP in patients.

Table (1) Comparison of studied data in androgenic alopecia at 6^th month between PRP and non-PRP groups.

NB: We are giving indicator grade from 1 (less or poor) to 5 (full length or density) for density 1= less than 25 hair follicle per 1 cm², 2= 25-30 hair follicle per 1 cm², 3= 30-35 hair follicle per 1 cm², 4= 35-40 hair follicle per 1 cm² & 5= 40-45 hair follicle for 1 cm², length ranged from 1 as starting of growth to 5 for full length.

Density and length which each of both examined and investigated by either trichoscopy or assessment by the surgeon.

This table shows:

A highly statistically significant difference (p-value < 0.001) between the PRP group and non-PRP group in androgenic alopecia at 6th months as regard density & length.

No statistically significant difference (p-value > 0.05) between PRP group and non-PRP group in androgenic alopecia at 6th months as regard Redness, patient satisfaction, and complications & rate of regrowth.

Figure (17) Comparison of density in androgenic alopecia at 6^th month between PRP and non-PRP groups.

Figure (18) Comparison of length in androgenic alopecia at 6^th month between PRP and non-PRP groups.

Table  (2) Comparison of studied data in Cicatricial alopecia at 6^th month between PRP and non-PRP groups.

This table shows:

A statistically significant difference (p-value < 0.05) between PRP group and non-PRP group in Cicatricial alopecia at 6th months as regard density, rate of regrowth, and length.

No statistically significant difference (p-value > 0.001) between the PRP group and non-PRP group in Cicatricial alopecia at 6th months as regard Redness, patient satisfaction, and complications.

Figure (19) Comparison of density in Cicatricial alopecia at 6^th month between PRP and non-PRP groups.

Figure (20) Comparison of length in Cicatricial alopecia at 6^th month between PRP and non-PRP groups.