Stem Cell Growth Factors and Baldness

There was a very interesting news item in field of hair transplant which I would like to share. This concerns cause of male pattern alopecia.
It is a known fact that in male pattern balding (Androgenetic alopecia), hair follicles don't disappear. They become so small by a process called “miniaturization” that they are not visible to naked eye. Although, we know that DHT is responsible for this process, how exactly it causes miniaturization of hair roots is still not known.

One theory of miniaturization says that DHT causes stem cell depletion in hair follicles of bald areas. A new study, published in the Journal of Clinical Investigation, tries to shed some light on this.  The research team led by Dr. Costarelis, MD collected cell samples from bald and non bald areas from the same persons and counted the number of stem cells present. They were surprised to find that bald areas had the same number of stem cells as hair bearing areas. When they looked further, they found that another cell type, which develops from stem cell, called progenitor cell was deficient in miniaturized follicle.

Dr Costarelis says that, "This implies that there is a problem in the activation of stem cells converting to progenitor cells in bald scalp." As of now, why or what causes the arrest in progression of stem cells to progenitor cells is not known. "However, the fact that there are normal numbers of stem cells in bald scalp gives us hope for reactivating those stem cells," notes Costarelis.
The logical next step would be to identify the factors that arrest this progression and to remove them. A locally applied agent or growth factors that can help stem cells to get converted to progenitor cells would also be very useful.
I have used growth factors injections in some of my patients. The results, especially when used with PRP are good but temporary. The repeated injections overcome the cost benefit. The big break will be an agent that can grow hair permanently. Till then we have hair transplants.

Top 5 Hair Loss Myths

When you are suffering from hair loss, every one will offer you an advice or two. From office boy to neighborhood auntie, each can tell you cause and remedy of your hair loss. How they became so knowledgeable is anybody’s guess but here is a list to tell you when they are right and when they are not.

Myth No.1 : Shaving the Head will Prevent Hair Loss

NO! NO! NO! Shaving does not prevent hair fall. Probably the origin of this myth lies in the fact that short stubble feels coarser and is therefore considered made of better quality hair. In fact, it only feels harder because the hair is short and not because hair quality has improved overnight.  

Another contributing factor to the popularity of this myth may be that you stop “seeing” hair loss. After shaving your head, you don’t see hair in your hands or pillow like you used to. This is again because the hair is so short that you don’t notice its fall and not because hair loss has stopped.

Remember, the hair is falling due to hair root injury and shaving can not change this process. Hair fall will continue even if you shave your head hundred times.

Myth No.2 :  Dandruff causes Hair Loss

Again not true. The origin of this myth is the fact that every time you scratch your scalp you get one or two hair in your hands. These are just weak telogen hair that were about to fall any way. Dandruff on the other hand is a surface infection or colonization by a fungus. It happens in oily scalp and is medically treatable. It does not cause any damage to hair roots. Also remember that flaking of dry scalp is different from dandruff and only requires good hair conditioner.

Myth No.3 : Tension causes Hair Loss

False.  I  don’t know where this came from. Severe prolonged stress due to injury or disease can cause telogen effluvium, but day to day stress does not exacerbate hair loss.

Myth No.4 : Helmet or Hat causes Hair Loss

Wrong. Tight helmets or hats may contribute to hair fiber damage, but it does not cause root injury. On the other hand, pulling the hair too hard while wearing a turban or cornrows, can cause permanent hair loss. This is called traction alopecia and requires surgical treatment.

Myth No.5 : Oiling Prevents Hair Loss

Not true. Adequate oil is produced by your scalp to nourish hair roots. In fact, evey hair has its own oil producing gland. If you have very long hair, then putting hair oils may improve the texture, but short hairs do not require oiling. Head massage with oils can relax you but does little for hair growth.

So, what causes hair loss? I shall discuss this in my next blog.

Hair Transplant: FAQs

What is Hair Transplant?

Word "Transplant" can be seen as  made of two  words, Transfer and Implant. So, hair transplant is simply transfer of living hair. These hair can be transplanted in any hairless area such as balding scalp or area of stable scar, eyebrow, moustache etc. Currently, this is the only technique that can give natural, permanent, growing hair in bald area.

Who Needs It?

Hair transplantation is used predominantly to treat the hereditary balding condition known as androgenetic alopecia ( Male pattern baldness). Patients with male pattern hair loss tend to loose hair from the front and top of their head. Since baldness is often ridiculed in society, it can undermine one's confidence and performance, especially if it comes at a young age.

Women with diffuse alopecia, selected patients with burn alopecia, eyebrow and facial hair loss patients are other candidates who can benefit from the procedure.

What Causes Hair Loss?

Although there are many causes of hair loss, the commonest cause is male pattern baldness. this is due to a combination of two factors. First, the hormonal byproduct Di Hydro Testosterone (DHT) and second your hair follicle's susceptibility to DHT, which is genetically determined. Both the factors should be present to cause hair loss.

How is Hair Transplant done?

Patients having baldness still have good density of permanent hair on the sides and back of the head. These good quality hair that naturally last a lifetime, are used to fill up the bald region. The hair are taken out from the scalp one by one (as single units called FUE)  and are implanted individually in the bald area. This highly sophisticated procedure replicates the natural hair growing pattern.

Is There Pain?

Hardly if any at all. I customise local anesthesia solution to gently numbs the area of procedure. You will not feel anything at all. even in post operative phase when anaesthesia effect wears off, only mild painkillers may be required. Some people do not require any painkiller after FUE method.

How Long Will It Take?

Hair transplant is a one day  procedure in office setting. No admission is required. An average surgery of 1500-2000 grafts takes 5-6 hours. Megasessions of 3000 or more grafts may take 8-10 hours. You can go home the same day after procedure.

Are Results Permanent?

Yes. Since transplanted hair come from permanent hair zone (the back and side of scalp) that is unaffected by DHT, these hair do not fall after implantation. They will have same texture, colour, growth and quality as your back hair and the results will last you a lifetime.

Why Shouldn't I go for Artificial Hair?

Entirely too many reasons. The biggest reason that my patients tell me is that they feel artificial. There is always that fear of losing face in public if the hair piece comes off. Then, of course, there is price for maintenance, price for replacement and price for touch ups. After some time the cost of maintaining a good hair piece crosses that of transplant and you still have nothing to show. Last but not the least is health reasons. The glue can cause allergy, the clips can cause headache,even wounds if they are too tight, weaving may pull and damage your existing hair

How Much Does it Cost?

The initial cost of a good hair transplant may be high but it does not require any maintenance. It is a kind of investment that will keep you giving good returns for times to come. An average a transplant session costs 5-7,000 US $ for FUT and 15-20,000 US $ for FUE hair transplants, but it is much cheaper in India.

Hair Transplant Surgery

Baldness and thinning of scalp hair are conditions that affect almost one-third of all men in their thirties and, fifty percent by their fifties.  Infrequently, some women also experience noticeable hair loss. There are many causes for hair loss including systemic diseases, severe infection, anemia, thyroid disease, protein, vitamin and mineral deficiency, certain drugs, cancer treatments, childbirth and birth control pills. In this type of hair fall the root of hair is not destroyed. Therefore hair loss is temporary and corrects after the offending agent is withdrawn. However, when hair root is destroyed, the loss of hair is permanent. This include direct trauma such as accidents or operations and inflammatory or infectious diseases of the scalp. But, the most common type of permanent hair loss is Androgenetic alopecia, the exact cause of which is not known. In this condition, hair loss occurs typically from front and top portions of head, while sides and back hair are retained.

Artificial coverage of bald area can be done with hairpieces and fibers, but many people find them unnatural looking or difficult to maintain. There are some medicines and oils in the market that claim to restore hair growth with limited success. Surgical hair transplant is the only predictable and permanent solution for those who are bald or have thinning hair. Hair transplants or grafting is a procedure which produces very favorable, permanent results for many people.

Am I Right Candidate for Hair Transplant?

You should plan a transplant if,

Your hairline is not appropriate for age or you wish to achieve younger looking hair line

You have burn alopecia or traction alopecia.

You have eyebrow, eyelash or facial hair loss.

You should wait if,

You are in your teens or early twenties with unstable hair line.

If you have rare genetic conditions like DUPA, extensive alopecia areata etc.

If you are medically unfit for surgery (uncontrolled blood pressure, uncontrolled diabetes, heart failure etc)

Even in these conditions, it is best to consult a qualified plastic and cosmetic surgeon; because he can help you chalk out a plan for future and may offer you alternative therapies. An honest expert advice can save you lot of grief.

Before Hair Transplant Surgery

Hair transplant or hair grafting or Hair restoration surgery puts natural, growing hair in bald areas. Your plastic and cosmetic surgeon will carefully examine both the area from which the grafts are to be taken (donor site) and the area to receive the grafts (recipient site) to see if they are compatible. The patient's type and pattern of hair loss are evaluated. The cosmetic surgeon and patient discuss how the hair should look in order to produce a pleasing, natural appearance. Photographs are often taken to evaluate the results. Blood tests may be advised to determine whether there are medical conditions such as bleeding or clotting defects that might make surgery inadvisable. Pre-operative instructions may include the elimination of drugs containing aspirin in order to minimize the possibility of excess bleeding.

The Hair Transplant Procedure

The surgery is done in a day care setting at plastic and cosmetic surgeon’s office or a surgical centre under local anesthesia. Immediately before hair restoration surgery, your surgeon will design a hairline for you and trim the donor hair. The area is cleansed with a special solution. There are two basic methods of harvesting the donor hair.

1. The strip method
2. Follicular extraction method

In the older strip method, a portion of skin containing hair and hair follicles is removed.This piece of skin is then cut into follicular hair units containing one to three hair. These follicular units are then used to refine the hairline. Some centers still use minigrafts, (5-7 hairs) or micrografts (3-4 hairs)but it is not popular now, because the results are not natural.

In advanced FUE (Follicular Unit Extraction) method, the hair grafts are harvested using micro punches from the scalp. This is a newer and more expensive method. Since the hair are harvested one by one no stiching is required and scars are also not visible.The donor grafts are carefully placed in a pattern that matches the direction of the original hair. The hair grafts are placed in such a way as to achieve adequate density while allowing each graft to receive an adequate blood supply during the healing process.

Following Hair Transplant Surgery

Following the procedure, the patient is required to wear a protective bandage. Patients may experience a moderate amount of discomfort which is controlled with oral medication. Risks and complications are rare because only the outer layer of the skin is involved. Rarely some swelling and around the eyes may occur two to three days after surgery. Using eye compresses and sleeping in a semi-reclining position can minimize these problems. Shampooing is allowed after bandage removal. Stitches, if used are removed around ten days after surgery.

Numbness around the donor and recipient sites is common and will diminish within two to three months. Scabs may be present on the hair grafts for seven to ten days. Small scars remain but are hidden within the hairline. About three to four weeks after hair restoration surgery, the hair begins to fall out. Approximately three months later, new hair appears and grows at about the same rate as it did in its original location, about one-quarter to one-half inch a month. Several treatment sessions may be necessary and patients who want to achieve greater density or refinement of the hairline often return for additional hair transplants. The end result is a hairline similar to the patient's original one.

Hair Cycle: Implications for Hair Transplant

Dear friends,

in my last blog I discussed about hair cycle. Today I will show you the implications of this knowledge in the field of hair transplantation.

As we know, hairs are in a constant cycle, and individual hair is in a differe nt stage of this cycle at any given point of time. If we assume that a person has 3 year anagen / 4 month telogen cycle he will have 25% hairs each at 0-1 yr anagen, 1-2 yr anagen, 2-3 yr anagen, around 5% each at 1,2,3,4 mth telogen and around 5% in catagen. Although, this is oversimplification of the actual hair state, it illustrates the point well. Now, once these hairs (in various phases of hair cycle) are transplanted, it is natural for them to grow out at different points of time. Usually this growth occurs between 4^th to 12^th month post transplant but, the new hair can come out even beyond the traditional 1 yr mark.

Another implication is rate of hair growth. If the no. Of transplanted hair has more anagen component and less telogen, the results will be apparent sooner. This kind of pick and choose is possible for FUE, but not for strip. That is why people see good early results with FUE. During strip a fair amount of telogen hair will be transplanted. Once this hair completes is dormant stage and becomes active again, you will see the growth. So be patient.

Many people who are not properly trained or are not aware of the concept of hair cycle can contribute to hair wastage. Usually, the technicians who are cutting the graft (in old strip method) will discard a seemingly thin hair because they “thought” it was an insignificant, useless hair. This same hair would have grown into a perfectly healthy hair, given time and nourishment. I think that as a criminal wastage of hair in already depleted scalp.

Also, many a times technicians who do not use magnification can mistake a two hair graft, with one anagen and one telogen, as a single hair. If such hairs are used for frontal hair line or temple restoration, an unnatural tufty appearance may occur. FUE circumvents this problem because each graft is harvested by surgeon under magnified vision.

Hair Cycle: What is Anagen hair?

You may have read terms like anagen, catagen and telogen hair but did not know what they are. Here is the answer.

In human scalp growing hairs are in a constant cycle. There is an active growing phase, called anagen phase, a stable phase with steadily diminishing hair strength called catagen and a degenerative phase in which hair falls out, called telogen phase. This is followed by a dormant period at the end of which new hair come out and anagen phase restarts.
I hope, I have not confused you further. So here is a pictorial representation of this cycle,

An anagen hair is an growing hair. It keeps on increasing in length and is thick and strong. It is darker in colour and will give more volume to the mane. The anagen phase lasts for 3-4 years but may be as long as 10 years in some lucky individuals. On the other hand, in Catagen phase, the growth of hair is over but it is yet to fall out of the scalp. These hair are frayed, thinner, weaker and less pigmented. After the hair falls out,  the hair root goes into a resting phase for 2-3 months. This is called Telogen phase.  In a healthy scalp about 80% hair are in anagen phase, while 10% each are in catagen & telogen phase.

So what does this mean for you ? Basically it means that in a balding patient there are more telogen hair and less anagen hair. If we can increase the number of anagen hair or if we can change the ratio of anagen to telogen hair, more volume of hair can be generated from the same hair roots. Anti hair-loss medicines can prolong the duration of anagen phase and improve hair length and texture.

In my next blog I will discuss the implications of hair cycle in transplant patients.

What is FUE hair transplantation?

I assume that you already know the theory behind hair loss and hair transplant. There are two basic methods of harvesing donor hair. The conventional strip technique and follicular unit extraction. In Follicular Unit Extraction (FUE) technique donor hair are harvested one by one and is therefore more labour intensive. During this technique a small micropunch usually sized 1mm or smaller is used to isolate a group of hair from its skin attachments. These groups having one to four hair, called follicular units, are then gathered (pulled out) from the head. This leaves a pin point wound from the area of harvest.

In this way the hair are taken out one after another, until adequate number of hair required for that session have been harvested. This surgery is done at a "micro" level and requires 8X magnification and expert hand control. Since FUE procedure requires careful and delicate handling, it is possible to harvest only 1200-1500 follicular units per session. An average session may last 8 hours and may need to be repeated, if balding area or graft requirement is extensive. The donor wounds heal over the next of seven to ten days with barely visible scars. Stiches are not required

In contrast, in FUT (strip) technique all the required hair are removed in one long strip of hair bearing skin. These hair are then isolated from the strip and implanted. To close the gap after strip harvest, stiching is required.

After the grafts are harvested, micro slits are created in the bald area where these follicular units are implanted with help of fine instruments. Once they develop their blood supply they will give rise to healthy growing hair. The angulation of hair, density in key areas and hair design remais different from surgeon to surgeon and depends upon his experience and expertise.
At the end of the day the difference is only in harvesting technique, but what a big difference is that.

In my next blog, i will discuss the advantages and disadvantages of each technique.