Management of Androgenetic Alopecia

1. Management of Androgenetic Alopecia Garrett Hauptman MD David Teller MD University of Texas Medical Branch Department of Otolaryngology December 7, 2005

2. Overview Embryology and Anatomy of Hair Androgenetic Alopecia Hair Growth Cycle Pathophysiology of Hair Loss Patient Evaluation Medical Treatment Surgical Treatment Historical Follicular Unit Transplantation

3. Embryology and Anatomy of Hair

4. Embryology of Hair Follicle Begin development between 9 and 12 weeks gestational age Hair production typically seen between 16 and 20 weeks gestational age

5. Embryology of Hair Follicle Derived from ectoderm and mesoderm Ectoderm Hair matrix cells Melanocytes Mesoderm Erector pili Dermal papilla Follicular sheath Blood vessels

6. Anatomy of Hair Shaft Surrounded by an outer and inner sheath Shaft composed of 3 layers Cuticle: outer layer Cortex: middle layer Medulla: inner layer

7. Follicular Unit Terminal hairs: 1-4 Vellus hairs: 1-2 Sebaceous glands: 9 Erector pili muscle: 9 Perifollicular vascular plexus Neural net Connective tissue

8. SCALP Layers Skin Connective tissue (subcutaneous tissue) Aponeurotica (galea aponeurotica) Loose connective tissue Pericranium

9. Blood Supply and Innervation Frontal Supratrochlear Supraorbital Temporal Superficial temporal Zygomaticotemporal Parietal Retroauricular Auriculotemporal, Great auricular, Lesser occipital Occipital Occipital Greater occipital

10. Alopecia

11. Alopecia Definition: Origin: Gr. Alepekia = a disease in which the hair falls out Loss of hair, wool, or feathers Absence of hair from skin areas where it is normally present

12. Types of Alopecia Alopecia adnata Alopecia areata Alopecia cicatrisata Alopecia conginitalis Alopecia disseminata Alopecia leprotica Alopecia marginalis Alopecia medicamentosa Alopecia mucinosa Alopecia pityrodes Alopecia presinilis Alopecia senilis Alopecia symptomatica Alopecia syphilitica Alopecia totalis Alopecia toxica Alopecia triangularis Alopecia triangularis congenitalis Alopecia universalis

13. Androgenetic Alopecia Definition Hereditary thinning of the hair induced by androgens in genetically susceptible men and women Also known as Male-pattern hair loss or common baldness in men Female-pattern hair loss in women

14. Androgenetic Alopecia Thinning of hair usually begins between 12 and 40 years old in males and females Approximately half the population expresses this trait to some degree before age 50 Inheritance is polygenic

15. Hair Growth Cycle

16. Hair Growth Cycle Stages Anagen = growth Catagen = involution Telogen = rest

17. Hair Growth Cycle Normal scalp activity Anagen = 90-95% Catagen = <1% Telogen = 5-10% At the end of telogen, hair is released and the next cycle is initiated Up to 100 hairs in telogen are shed each day and about the same number of follicles enter anagen

18. Hair Growth Cycle

19. Pathophysiology of Hair Loss

20. Pathophysiology of Hair Loss Dihydrotestosterone Formed by peripheral conversion of testosterone by 5-alpha reductase Binds to androgen receptor on susceptible hair follicles Hormone-receptor complex activates genes responsible for gradual transformation of large terminal follicles to miniaturized follicles

21. Pathophysiology of Hair Loss: Miniaturization

22. Pathophysiology of Hair Loss: Miniaturization Progressive diminution of hair shaft diameter and length in response to systemic androgens

23. Patient Evaluation

24. Patient Evaluation Androgenetic alopecia diagnosis Characteristic pattern of hair loss Miniaturization in thinning areas Family history is supportive but not necessary

25. Patient Evaluation Evaluate for miniaturization using a densitometer to observe small area of clipped scalp

26. Patient Evaluation Normal scalp Thick terminal hair Fine vellus hair Miniaturization Thick terminal hair Fine vellus hair Intermediate diameter hair

27. Patient Evaluation Regions of the scalp

28. Patient Evaluation Norwood Classification Most widely used classification of male-pattern hair loss 2 types Common type Type A variant

29. Patient Evaluation

30. Patient Evaluation

31. Patient Evaluation

32. Patient Evaluation

33. Patient Evaluation Studies reveal negative psychosocial impact with hair loss Body image dissatisfaction Negative stereotype: Older Weaker Less attractive Counsel patients on expectations with treatment

34. Medical Treatment

35. Medical Treatment Goals Increase coverage of the scalp Retard further hair thinning Drugs Minoxidil: unknown mechanism for hair growth stimulation Finasteride: competitive inhibitor of type 2 5-alpha reductase Dutasteride: competitive inhibitor of type 1 and 2 5-alpha reductase

36. Medical Treatment Effect of Minoxidil applied topically at 2% and 5% concentrations BID (NEJM 1999- VH Price)

37. Medical Treatment Effect of Finasteride given at 1mg PO QD (NEJM 1999- VH Price)

38. Medical Treatment Effect of Dutasteride given at 0.5mg PO QD in 1 patient (J Drugs Derm 2005- M Olszewska et al)

39. Surgical Techniques Goal Achieve the greatest hair density while retaining complete undetectability and natural appearance

40. Surgical Techniques Scalp Reduction Scalp Flaps Hair Transplantation

41. Scalp Reduction Originally described in 1978 by Unger and Unger Excise non-hair-bearing scalp in excision pattern suitable for patient Saggital midline ellipse “Y” pattern Lateral patterns (“S”, “J”, and “C”) “U” pattern Miscellaneous patterns (“T”, “I”, transverse ellipse, crescent ellipse)

42. Scalp Reduction Bald scalp excised to pericranium, but not through pericranium Wide undermining with primary closure

43. Scalp Reduction

44. Scalp Reduction

45. Scalp Reduction Complications Excessive scalp excision Tension on wound closure Possible tissue necrosis Scar widening “Stretch-Back” Tendency of bald scalp to expand after each reduction Between 10-50% of total reduction Majority occurs within 2 months of surgery

46. Scalp Reduction Techniques Opposing “Stretch-Back” Scalp Extenders Silastic with hooks attached to deep galeal surface with hooks parallel to incision Anchoring Galeal Flaps Rectangular galea strips on one side of incision sutured to undersurface of opposing flap Nordstrom Suture Elastic silicone polymer suture attached to galea

47. Scalp Flaps Advancement or rotation of hair-bearing scalp Provides immediate coverage of alopecic areas Types Lateral Scalp Flap Temporoparietooccipital Flap (Juri Flap or Fleming-Mayer Flap) Preauricular Flap Free Scalp Flaps

48. Scalp Flaps Complications Elevation of hairline associated with donor region Possibility of flap necrosis and donor area necrosis Unnatural appearance of hair growth direction

49. Tissue Expanders Increases surface area of hair-bearing scalp Placed between galea and pericranium Used in conjunction with Scalp Reduction and Scalp Flaps

50. Tissue Expanders

51. Follicular Unit Transplantation Patient Preparation Anesthesia Graft Harvesting Graft Dissection Recipient Sites Post-op Care

52. Follicular Unit Transplantation Technique pioneered by Dr. Bobby Limmer Graft Dissection Technique Separate follicular units from surrounding tissue Want small grafts with minimal epithelium to allow for Smallest recipient site necessary Limits skin trauma and preserves blood supply Avoid disrupting unit structures

53. Follicular Unit Transplantation Follicular graft units have between 1 and 4 hair follicles

54. Follicular Unit Transplantation Patient preparation Upright position Trim donor area to 1-2mm with electric clippers From occipital protuberance medially to over ears laterally

55. Follicular Unit Transplantation Oral sedation may be used Local anesthesia Mixture of 60% lidocaine 0.5% and 40% bupivacaine 0.025% with 1:200,000 epinephrine and sodium bicarbonate 8.4%, 1:20 Lidocaine for quick onset Bupivacaine for increased duration Epinephrine for hemostasis and increased duration Sodium bicarbonate to decrease stinging

56. Follicular Unit Transplantation Donor area anesthesia Inject into deep subcutaneous fat layer Extend injection 1cm inferiorly and several cm lateral of graft margins Recipient area anesthesia Inject into superficial dermis and subcutaneous space

57. Follicular Unit Transplantation After initial injections, tumescent anesthesia administered to midfat Lidocaine 0.17% and epinephrine 1:600,000 Purpose Increases follicular distance from nerves and blood vessels Increases ridgidity of donor area Decreases bleeding More uniform anesthesia Reduce total amount of anesthesia required

58. Follicular Unit Transplantation Graft harvesting Follicular Unit Extraction Involves individual unit harvesting by making using a punch Good for minimal hair loss Does not leave linear scar if people wear hair short Only 2-3 people can work at once Donor Strip Harvest Currently used method

59. Follicular Unit Transplantation Donor Strip Harvest 1cm wide graft is harvested from posterior middle scalp at the external occipital protuberance- “the permanent zone” Want to be above muscular insertion Do not want to harvest from a potential area of future hair loss

60. Follicular Unit Transplantation Donor Strip Harvest Best performed with Rassman handle loaded with two 10 blades set 1.2cm apart Handle holds blades angled at 30 degrees to minimize follicular transection May be performed freehand with 10 blade Pro: allows blade angle to be adjusted Con: difficult to keep width uniform

61. Follicular Unit Transplantation

62. Follicular Unit Transplantation Donor strip elevated in subcutaneous plane

63. Follicular Unit Transplantation Strip ends are tapered to 1.5 strip width for closure purposes Preferred closure method with 5-0 absorbable suture Running skin stitch 1.5mm from wound edge Advance approximately 5mm Minimizes entrapment and destruction of follicles

64. Follicular Unit Transplantation

65. Follicular Unit Transplantation Staples also can be used for closure Pro: No tissue reactivity Cons: Difficult wound apposition Uncomfortable for patient May result in stretched scar

66. Follicular Unit Transplantation

67. Follicular Unit Transplantation One square cm of donor tissue yields approximately 100 follicular units

68. Follicular Unit Transplantation Graft Dissection Stereomicroscope Divide donor strip into thin sections- “slivering” Avoid follicle transection Avoid dividing follicular units

69. Follicular Unit Transplantation

70. Follicular Unit Transplantation

71. Follicular Unit Transplantation Slivers are then dissected into individual follicular units

72. Follicular Unit Transplantation

73. Follicular Unit Transplantation Follicular units are sorted based on hair number into petri dishes of Ringer’s lactate or saline on ice

74. Follicular Unit Transplantation Recipient Sites Do not use instrument that will remove tissue Keep recipient sites small, but large enough so that grafts do not need to be forced in place Visible scars are not produced by needles 18 gauge or less

75. Follicular Unit Transplantation Recipient Sites Instrument size guide equivalents 20 gauge = 1-hair unit 19 gauge = 2-hair and thin 3-hair units 18 gauge = 3-hair and 4-hair units

76. Follicular Unit Transplantation Recipient Sites Techniques Stick and Plant Grafts are placed immediately after creation of recipient site “Premaking” recipient sites All recipient sites created prior to grafting

77. Follicular Unit Transplantation Stick and Plant Technique Pros Needle can be used to facilitate graft placement Sites do not go unfilled Avoids placing 2 grafts in one site Cons Increased risk of dislodging (“popping”) adjacent graft when creating site Must focus on design elements (angling and distribution) while performing technical aspect

78. Follicular Unit Transplantation “Premaking” Recipient Sites Pros Physician concentrates on design without distraction of graft handling or risk of popping Allows time for coagulation improving visibility and placement Cons Must estimate graft number Unfilled recipient sites 2 grafts in one site (“piggybacking”)

79. Follicular Unit Transplantation Hair direction Grafts placed at original growing angle, not direction of hair grooming Hair anterior to vertex transition point should point forward Angle becomes more acute as it reaches the anterior hairline

80. Follicular Unit Transplantation

81. Follicular Unit Transplantation Recipient Site Density Average non-balding scalp has 100 follicular units per square cm 50% of hair may be lost before noticeable thinning Wasteful for more than 50% to be replaced Up to 25 follicular units per square cm into frontal area of balding scalp is recommended

82. Follicular Unit Transplantation Recipient Site Distribution Creating greatest density in front part of scalp produces best cosmetic result (“Forward Weighting”) Recipient sites placed closer together Larger follicular units placed (3-4 hairs) Recipient site density should be gradually tapered toward the crown

83. Follicular Unit Transplantation “Forward Weighting”

84. Follicular Unit Transplantation

85. Follicular Unit Transplantation

86. Follicular Unit Transplantation

87. Follicular Unit Transplantation

88. Follicular Unit Transplantation

89. Follicular Unit Transplantation Operative time typically 3 to 6 hours

90. Follicular Unit Transplantation Postoperative Care Wash scalp with sterile water Avoid using peroxide Apply antibiotic ointment and pressure headband dressing to donor site Cover transplanted area with surgeon’s cap

91. Follicular Unit Transplantation Postoperative Care Patient to have hair washed on post-op day 1 to remove crusts Some surgeon’s have patient return to clinic for this, some permit patient to wash hair Return to clinic in 1 week No strenuous activity for one week Pain medication Photoprotection for 3 months

92. Follicular Unit Transplantation

93. Follicular Unit Transplantation

94. Follicular Unit Transplantation

95. Follicular Unit Transplantation Problems and Complications Poor patient selection Operating on young patients is difficult Hairline creation looks unnatural long term Do not know donor site stability Poor aesthetic judgment Grafts in wrong direction Crown transplant in young patient who is just starting to lose hair Improper graft handling Wide donor scars

96. Follicular Unit Transplantation More than one procedure is often necessary Wait at least 6 to 8 months between procedures

97. Conclusions Evaluate and counsel patient Consider medical management Follicular Unit Transplantation is surgical technique of choice today

98. Baldness Portrays Being Older and Wiser

99. Bald Can Be Funny

100. Bald is Beautiful

101. Or Is It?

102. Bibliography Portions of this paper and presentation were taken directly form the May 29, 2002 Grand Rounds presentation by Elizabeth Rosen and Karen Calhoun entitled Management of Alopecia. Bernstein, RM, et al. Follicular Unit Transplantation: 2005. Dermatology Clinics 2005 , 23; 393-414. Harris, JA. Follicular Unit Transplantation: Dissecting and Planting Techniques. Facial Plastic Surgery Clinics of North America 2004, 12; 225-232. Epstein, JS. Follicular-Unit Hair Grafting. Archives of Facial Plastic Surgery 2003, 5; 439-444. Price, VH. Treatment of Hair Loss. New England Journal of Medicine, September 23, 1999; 341 (13); 964-973. Olszewska, M, et al. Effective Treatment of Female Androgenic Alopecia with Dutasteride. Journal of Drugs in Dermatology 2005, 4;637. Nordstrom, RE. Scalp, Hair, Baldness, and Surgery. Facial Plastic Surgery. 1985, 2 (3); 173-177. Barrera, A. Hair Transplantation, The Art of Micrografting and Minigrafting. Quality Medical Publishing, Inc, St.Louis; 2002. Abell, E. Embryology and Anatomy of the Hair Follicle. In, Disorders of Hair Growth, Diagnosis and Treatment, E.A.Olsen, ed. McGraw-Hill, Inc, New York; 1994. Sinclair, R. Male Pattern Androgenetic Alopecia. British Medical Journal. 1998, 317; 865-869. Ramos-e-Silva, M. Male Pattern Hair Loss: Prevention Rather Than Regrowth. International Journal of Dermatology. Oct 2000, 39 (10); 728-731. Nordstrom, RE. The Initial Interview. Facial Plastic Surgery. 1985, 2 (3); 179-187. Devine, JW, Howard, PS. Classification of Donor Hair in Male Pattern Baldness and Operations for Each Type. Facial Plastic Surgery. 1985, 2 (3); 189-191. Price, VH. Drug Therapy: Treatment of Hair Loss. The New England Journal of Medicine. Sept 23 1999, 341 (13); 964-973. Unger, MG. Scalp Reductions. Facial Plastic Surgery. 1985, 2 (3); 253-258. Raposio, E, Nordstrom, RE. Tension and Flap Advancement in the Human Scalp. Annals of Plastic Surgery. July 1997, 39 (1); 20-23. Raposio, E, PierLuigi, S, Nordstrom, RE. Effects of Galeotomies on Scalp Flaps. Annals of Plastic Surgery. July 1998, 41 (1); 17-21. Norwood, OT, Shiell, RC, Morrison, ID. Complications and Problems of Scalp Reductions. Facial Plastic Surgery. 1985, 2 (3); 259-267. Frechet, P. Scalp Extension. Journal of Dermatologic Surgery and Oncology. 1993, 19; 616-622. Raposio, E, et al. Anchoring Galeal Flaps for Scalp Reduction Procedures. Plastic and Reconstructive Surgery. Dec 1998, 102 (7); 2454-2458. Nordstrom, RE, Greco, M, Raposio, E. The “Nordstrom Suture” to Enhance Scalp Reductions. Plastic and Reconstructive Surgery. Feb 2001, 107 (2); 577-582. Argenta, LC, Marks, MW, Anderson, RA. Treatment of Male Pattern Baldness by Tissue Expanders. In, Male Aesthetic Surgery, 2nd Ed, EH Courtiss, ed. Mosby, St.Louis; 1991. Juri, J, Juri, C. The Juri Flap. Facial Plastic Surgery. 1985, 2 (3); 269-282. Unger, WP. Construction of the Hairline in Punch Transplanting. Facial Plastic Surgery. 1985, 2 (3); 221-230. Vallis, CP. Treatment of Male Pattern Baldness by Punches, Strips, and Flaps. In, Male Aesthetic Surgery, 2nd Ed, EH Courtiss, ed. Mosby, St.Louis; 1991. Vallis, CP. The Strip Graft. Facial Plastic Surgery. 1985, 2 (3); 245-252. Epstein, JS. Revision Surgical Hair Restoration: Repair of Undesirable Results. Plastic and Reconstructive Surgery. July 1999, 104 (1); 222-232. Vogel, JE. Correction of the Cornrow Hair Transplant and Other Common Problems in Surgical Hair Restoration. Plastic and Reconstructive Surgery. Apr 2000, 105 (4); 1528-1536.

103. Quiz

104. Question 1 Hair development begins at what gestational age? A. 1 - 4 weeks B. 5 – 8 weeks C. 9 – 12 weeks D. 13 – 16 weeks

105. Question 2 List the components of a follicular unit

106. Question 3 Which drugs are approved by the FDA to treat hair loss A. dutasteride B. minoxidil C. viagra D. finasteride E. colace

107. Question 4 What is the name of one of the main classification schemes for male pattern alopecia?

108. Question 5 True or false: Micrografts are 1 – 2 hairs and minigrafts are 3 – 4 hairs.

109. Question 6 True or false: Follicular unit transplantation must be done under general anesthesia.

110. Question 7 How many follicular units are expected from 1 square cm of donor tissue?

111. Question 8 True or false: Grafts can be placed immediately after making the recipient site (“stick and plant”).

112. Question 9 True or false: Follicular units should be placed in the direction that hair grooming will take place.

113. Question 10 True or false: Only one procedure is necessary with follicular unit transplantation.