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Background: There are 2 extraction techniques for follicular units (FUs) in hair transplantation: strip harvesting follicular unit transplantation (FUT) and follicular unit excision (FUE). Currently, no extant studies have demonstrated that one technique is superior in extraction and donor area optimization for a dense result., Objective: This study compares the FUT and FUE techniques by evaluating the percentage of FUs with 3 or more hairs and the hairs-to-follicular-unit ratio in patients who underwent both procedures at different times., Materials and Methods: The medical records of patients who underwent at least 1 FUT procedure and at least 1 FUE procedure (with this being the second surgical procedure) were reviewed. The surgeries were performed in the same clinic with the same surgeon and surgical team., Results: There was a higher percentage of FUs with 3 or more hairs and a higher hairs-to-follicular-unit ratio with the FUE technique than with the FUT technique., Conclusion: In FUE, surgeons tend to choose better-looking FUs with thick, plentiful hairs. Even with these results, it is impossible to declare one procedure superior because the correct indication considers multiple factors., (Copyright © 2024 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Platelet-rich plasma (PRP) and its combined therapeutic modalities have catalyzed new possibilities in dermatology; however, limitations in evidence and lack of consensus remain among clinicians regarding optimal composition, protocol, technique, and application., Objective: To provide an update and analysis of the evidence for PRP in hair restoration and skin rejuvenation through review of recent available data, highlighting controversies and expert insights to guide future studies, and stimulate discourse and innovations benefitting patients., Methods: A structured review and expert analysis of PubMed publications before October 2023, with a focus on recent literature from January 2020 through October 2023., Results and Conclusion: Growing literature supports the utility and benefits of PRP and related autologous products for applications for skin and hair, with strongest evidence for androgenetic alopecia and skin rejuvenation. However, this is limited by lack of consensus regarding best practices and protocols. Randomized, controlled trials with uniform metrics comparing outcomes of various compositions of autologous blood products, preparation methods, dosimetry, and frequency of treatments are still required. This will allow the medical discourse to grow beyond the realm of expert opinion into consensus, standardization, and more wide spread adoption of best practices that will benefit patients., (Copyright © 2024 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To describe a case of endogenous endophthalmitis as a complication from hair transplantation., Methods: Case report of a 53-year-old man with a history of recent hair transplantation., Results: The patient presented with a febrile illness and blurry vision 1 week after hair transplantation. Infectious workup included blood cultures positive for methicillin-resistant Staphylococcus aureus, and he was treated with IV antibiotics. Initial ocular examination demonstrated 20/30 and hand motions in the right and left eyes, respectively, with significant vitritis. He underwent vitreous tap and injections of vancomycin and dexamethasone in both eyes and removal of purulent staple from the site of recently transplanted hair. His ocular and systemic symptoms improved. Approximately 3 months after initial clearing of the initial infection he had recurrence of bacteremia that prompted repeat intravitreal and systemic antibiotics. His vision returned to baseline with mild residual optic nerve pallor and atrophic retinal changes in the left eye., Conclusion: Hair transplantation is associated with minimal systemic complications, but in rare cases, sepsis is possible and can result in intraocular seeding causing endophthalmitis. MRSA endogenous endophthalmitis frequently results in negative vitreous taps and treatment outcomes in the literature have been shown to vary widely including a return to baseline vision as in the described case.

Background: Follicular unit excision is a favored minimally invasive hair transplantation method. However, it is suboptimal for many patients of African descent because of wide variations in hair and skin characteristics., Objective: To evaluate the performance of a skin-responsive follicular unit excision device, which accommodates hair curliness, skin thickness, and firmness in patients of African descent., Materials and Methods: The authors retrospectively evaluated patients who underwent scalp follicular unit (FU) excision using a skin-responsive technique at 7 multinational clinics. The preoperative donor grading for the anticipated difficulty used a scale with Class V indicating the highest degree of hair curliness, skin thickness, and firmness., Results: Of 64 eligible patients (45 males and 19 females), 28 had Class V FU excision donor grades. The mean transection rate for all patients was 3%-6%, which was highest in class V patients. Skin thickness and firmness had a greater effect on the maximum transection rate than hair curliness. Only 19 or 18 G punches were used., Conclusion: The authors report consistence success of a new skin-responsive FU excision device for all patients of African descent with a mean graft transection rate of less than 10%. The findings support skin thickness and firmness as major influencers of graft attrition rate., Competing Interests: Dr. S. Umar owns shares, patents, and patent applications for the reported FUE device issued to Dr. U Devices Inc. (Patent Nos: USPTO US8876847B2 and USPTO US9095368B3) and pending with Dr. Devices Inc. (Patent Application: PCT WO2019203882A1) and reports no other potential conflicts of interest for this work. All remaining authors have no conflicts of interest to declare., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society for Dermatologic Surgery, Inc.)

Background: Limited information exists on the long-term risks to individuals undergoing procedures in hair restoration surgery. The short-term risks are well known and similar to other procedures in dermatologic surgery. The long-term risks of hair restoration surgery are seldom discussed between the physician and patient., Objective: The author sought to describe a classification system that can be used as a communication tool between physicians and patients to define the long-term risk involved with hair restoration surgery., Methods: The Progressive Loss (PL) Scale is an attempt at assessing the cosmesis because of future hair loss following a hair transplant procedure. The PL Risk Scale has designated 5 levels, 1 to 5, with each ascending level representing a higher level of risk. The PL Risk Scale can be assigned to an individual at the time of the assessment for hair restoration surgery., Results: Each patient can be assigned a risk level based on how future hair loss may affect the overall cosmetic result of their hair transplant. This risk is dependent on age, and specific for the area to be transplanted. The younger the age of the patient, the higher the risk. The larger the area to be transplanted, the higher the risk. It is not a static scale, because it will be affected by age, donor area, location of transplantation, and other mitigating factors., Conclusion: Pattern baldness in men and women is progressive and unrelenting. The dichotomy of hair restoration surgery is that a satisfactory short-term outcome can evolve to disappointing results because of progressive hair loss. The PL Risk Scale can be assigned to every individual undergoing a hair restoration procedure. This scale assignment will convey to the patient their lifetime risk associated with any given surgical hair restoration procedure for that age and the specific area to be restored., (Copyright © 2022 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: The frontal-temporal triangle area (FTTA) hair has a slow growth rate and thin caliber, which are similar to those of eyebrow hair. However, a comparison of cosmetic outcomes between FTTA and other scalp hair grafts in eyebrow transplantation has not been performed., Objective: To compare the cosmetic outcomes of FTTA hair and periauricular and occipital area (POA) hair in eyebrow restoration., Methods: A retrospective analysis of 155 patients with FTTA or POA hair transplants was performed. Comparative variables included patient characteristics, hair density, diameter, percentage of one-hair follicular units (FUs), number of transplanted FUs, harvesting time, transection rate, hair survival rate, frequency of eyebrow trimming, and patient satisfaction., Results: There was a significant difference in hair density, diameter, percentage of one-hair FUs, and harvesting time between the FTTA and POA hair transplants. The FTTA hair grew significantly slower than the POA hair did. The patients in the FTTA group trimmed their postoperative eyebrows at a significantly longer interval than those in the POA group. The percentage of patients who were very satisfied with the surgery results was higher in the FTTA group., Conclusion: The FTTA hair grafts can provide aesthetically pleasing cosmetic results in eyebrow restoration., (Copyright © 2022 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Hair transplantation in scarring alopecia is challenging and transplant surgeons are hesitant due to fear of poor graft survival apart from the risk of reactivating the disease., Objective: Survival rate of hair follicles transplanted in cases of lichen planopilaris (LPP). To correlate histopathological and ultrasonography findings and their impact on graft survival., Methods: In 32 patients of inactive LPP included, a 5-cm2 recipient area was tattooed. The follicular unit density of the transplanted area was 20 to 25 FU/cm2. Postoperative follow-up was conducted at 6, 12, and 24 months. The recipient area density and ultrasound biomicroscopic parameters were assessed at each follow-up visit., Results: The survival of grafts was 78.62% at 12 months, and 79.96% at 24 months. Histopathology variables studied at the time of transplantation such as epidermal atrophy, fibrosis, and inflammatory infiltrate were not found to have any effect on the graft survival. Ultrasonography parameters of the involved scalp skin were found to be markedly improved on follow-up. This suggests that the overall health of the scalp improved after hair transplantation., Conclusion: Follicular unit excision is a ray of hope for cases of primary cicatricial alopecia such as LPP because the result is satisfying to both the patient as well as the doctor., (Copyright © 2021 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Transgender individuals experience common and unique dermatologic concerns from severe acne associated with testosterone therapy in transmen to complications due to illicit silicone injections in transwomen. Currently, 2 survey studies and 4 reviews have addressed the dermatologic care of transgender individuals. However, none of them provide a focus on the dermatologic surgeon., Objective: To assess the dermatologic considerations in transgender individuals and the role of dermatologic surgeon in their care., Methods: The PubMed and MEDLINE databases were reviewed in June 2018 using keywords, such as transgender, procedures, hair removal, laser, and hormone therapy., Results: In total, 48 relevant publications addressing dermatologic care in transgender patients were reviewed. According to the literature, there are several critical dermatologic considerations in transgender patients, including hair growth and removal, acne vulgaris, facial procedures to masculinize and feminize the face, scar removal, and sexually transmitted infections., Conclusion: As dermatologic surgeons have the privilege to improve the health care of transgender patients, they must understand the common and unique concerns of transgender individuals. Given the considerable spectrum of physical goals expressed by transmen and transwomen, individual patient preference must ultimately guide his/her/their dermatologic care.

Background: Female hairline restoration has increasingly been in demand for the past decade. However, no reports address the correlation between characteristics of hair at the hairline and at the donor area., Objective: To assess follicular characteristics at the hairline and at the donor area including hair density, diameter, and their correlation., Materials and Methods: One hundred one randomly selected Southeast Asian female volunteers were assessed for hairline and donor area characteristics. Data from the donor sites, including the temporal, parietal, occipital, and neck region were compared with that of the hairline., Results: Hairline density was 135.2 hair/cm with a diameter of 80.07 μm in midline, 112.95 hair/cm with 73.96 μm at the frontotemporal area, 69.82 hair/cm with 72.09 μm at temple peak, and 74.26 hair/cm with 72.35 μm at sideburns. The donor hair density was 98.89 to 152.19 hairs/cm and hair diameter was 76.80 to 81.11 μm. Aging was shown to affect hair density and diameter at the donor area., Conclusion: All donor sites are suitable for hairline restoration of the midfrontal region except in the neck region. The suitable donor area for the frontotemporal area, temple peak, and sideburns is the nape. Hair density and diameter declined with age at some donor sites.

Background: Hair density, together with hair diameter has a tremendous impact on the cosmetic outcome of hair transplantation surgery., Objective: This retrospective study aims to assess the average number of follicular unit (FU) grafts in the donor area of Asian men with androgenetic alopecia., Methods: Seventy patients (ages 24-65 years old) with virgin scalp who had their first hair transplantation were included. During the harvesting procedure, a 2- to 3-cm-wide area of the donor site was shaved from ear to ear with 5 specific areas assigned as reference points for the study namely the central occipital area, left and right parietal and temporal areas. A video microscope was used to capture the field of each reference point. Follicular units in each area were counted and the number of 1-hair, 2-hair, and 3-hair follicular groupings was recorded., Results: East and Southeast Asians had an average of 61.1 FU/cm (111.2 hairs/cm); West Asians had an average density of 63.6 FU/cm (126.8 hairs/cm); South Asians were noted to have an average density of 63.5 FU/cm (126.8 hairs/cm)., Conclusion: Asian hair density has slight variations in the number of FU grafts in each donor area.

Background: Hair transplantation requires precise evaluation of donor site laxity, elasticity, and glidability., Objective: The purpose of this study was to examine the relationship between donor strip scar width and preoperative laxity, elasticity, and glidability., Materials and Methods: Preoperative measurements of scalp laxity, elasticity, and glidability and of donor site scar width 10 months postoperatively were evaluated in 88 patients who underwent hair transplantation with strip harvesting. Elasticity was measured by firmly pressing the scalp with the fingertips of one hand at 2 points to restrict dermis movement while stretching the skin with the other hand. Glidability was calculated as laxity minus elasticity., Results: Scar width positively correlated with laxity (p < .01) and elasticity (p < .05) but had no relationship with glidability. There was a significant difference between patients in the upper 30th percentile of elasticity (≥10 mm) versus others (<10 mm) in scar width., Conclusion: Scalp laxity, elasticity, and glidability are of great clinical importance in hair transplantation. The authors' novel method of measuring elasticity will assist surgeons in predicting donor site scar width.

Background: In East Asian countries, hair transplantation is a quite common procedure for treating pattern hair loss, cosmetically correcting the hairline, and correcting eyebrow and pubic hair defects. Although there are general guidelines concerning hair transplantation, certain factors need to be addressed to make the guidelines more specific and suitable to East Asian requirements., Objective: To provide guidelines for hairline design, donor harvesting, graft preparation and placement, and medical treatment that are appropriate for hair transplantation in East Asian patients., Methods: Recommendations are based on the experience of the authors, surgeons who perform hair transplantation, and a comprehensive review of the available literature on hair transplantation in East Asians., Results: Data on hair thickness and graft density, hairline design, and graft creation and placement techniques have been collaboratively evaluated and used to establish overall guidelines., Conclusion: The use of the proposed guidelines by surgeons will hopefully enhance outcomes and bring greater consistency to hair transplantation procedures for East Asian patients.

Background: Few studies illustrate the contributions made by various specialties in pioneering commonly performed noninvasive and minimally invasive cosmetic and surgical procedures., Objective: To evaluate the contributions made by various specialties in pioneering noninvasive and minimally invasive cosmetic and surgical procedures., Materials and Methods: Key words using the Medical Search Headings Database were used to query in the Thomson Reuters Web of Science Database. The 25 most highly cited studies were sorted according to the citation number. The author specialty was identified and assigned scores based on the number of citations., Results: Dermatology was identified as the specialty with the greatest contribution to botulinum toxin treatments for rhytides, injectable fillers, laser treatments, chemical peels, and noninvasive body contouring. Neurology was identified as the leading specialty in botulinum toxin treatments for hyperhidrosis, and vascular surgery was identified as leading specialty in sclerotherapy. Plastic surgery was identified as having made the greatest contribution to hair transplantation, and liposuction., Conclusion: Dermatology was identified as the leading specialty for the majority of noninvasive and minimally invasive cosmetic procedures. Other specialties have also contributed important literature to this area.

Background: Scalp laxity is a major factor in achieving the maximum number of grafts in donor harvesting during hair restoration surgery. Proper assessment is important for each individual but especially so in patients presenting tight scalp., Objective: To validate cross beam laser (CBL) for scalp laxity assessment in comparison with Mayer elasticity scale (MES)., Materials and Methods: In a retrospective study of 165 patients, both CBL and MES were used to evaluate scalp laxity in vertical plane at the center and lateral area before surgery. The real width (RW) of donor strip during surgery was considered the gold standard., Results: Spearman correlation coefficient revealed that the CBL width was significantly correlated with the MES width in the following subgroups: (1) subjects undergoing their first session, (2) subsequent session patients, and (3) patients who required maximum number of grafts. Although the CBL width was statistically significant when compared with the RW in certain areas, whereas the MES width was statistically significant in all areas, the differences between the CBL width and the RW were minimal and clinically insignificant., Conclusion: The accuracy of scalp laxity measurements using the CBL procedure establishes CBL as a reliable tool for hair restoration surgery.

Background: Central centrifugal cicatricial alopecia (CCCA) is a progressive primary scarring alopecia that occurs mainly on the vertex of the scalp and expands centrifugally. To date, there is a paucity of published prospective studies reporting successful surgical therapy for CCCA., Objective: To evaluate the efficacy of hair transplantation using the round (punch) grafting technique in African American women with CCCA., Materials and Methods: We describe 2 African American female patients with CCCA who had endured nearly 5 to 6 years of progressive hair loss on the crown of the scalp. After a scalp biopsy and hair transplant test session, both patients underwent hair transplantation with the use of round grafts. Digital photographs were obtained before and after hair transplantation to determine the hair growth success and response rates., Results: Hair growth was visibly observed at the recipient sites in both patients beginning between 4 to 5 months post-test session. No postoperative scarring in the recipient or donor areas of the scalp were noted in either patient., Conclusion: Hair transplantation is a safe well-tolerated procedure to improve hair loss in African American women with end-stage CCCA who histologically display a lack of inflammation on scalp biopsy.

Background: Quantitative estimates of the yield of follicular units (FUs) containing likely "permanent" hair for hair transplanting have been only theoretically estimated., Objective: To clarify the number of likely permanent hair follicles in potential donor areas., Methods and Materials: Thirty-four highly experienced surgeons were surveyed and estimated the number of FUs containing "permanent" hair in hypothetical 30-year-old male patients with varying hair densities and destined to develop Type V or VI male pattern baldness (MPB)., Results: Patients with average hair density and destined to develop Type V MPB were estimated to yield an average of 6,404 FUs, 4,963 FUs with below average density, and 7,904 FUs with above-average density. When Type VI MPB is anticipated, estimated mean harvest yields are 5,393 FUs with average density, 4,204 FUs with below-average density, and 6,661 FUs with above-average density., Conclusion: There are a finite number of FUs containing permanent hairs in any patient. The results of this survey provide a guideline that should be helpful in avoiding inappropriately aggressive goals such as creating overly dense or overly anterior frontal and temporal hairlines without regard for a cautious evaluation of the limitations of likely long-term donor/recipient area ratios. We present useful guideline numbers that can help physicians choose appropriate surgical goals., (© 2012 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)

Background: Lichen planopilaris (LPP) is a type of primary scarring alopecia. The pathogenesis is poorly understood, although traumatic skin injury has been implicated in some cases., Objective: To present 17 patients diagnosed with LPP after hair transplant surgery., Materials and Methods: A retrospective review of the records of patients referred for evaluation of suboptimal growth after hair transplantation and diagnosed with LPP. Patients' scalps were evaluated using dermoscopy, and scalp biopsies were performed in all patients to confirm the diagnosis of LPP., Discussion: Seventeen patients (15 male, 2 female) were diagnosed with LPP after hair transplant surgery. The timing of disease occurrence was variable--4 to 36 months after hair transplantation. The most common symptom was itching. Perifollicular erythema or perifollicular scale, the classical dermatoscopic signs of LPP,was present in 12 patients (70%)., Conclusion: These data provide further support for an association between hair transplant surgery and the development of LPP. Traumatic skin injury from recipient site creation may be relevant to the pathogenesis. The incidence of this phenomenon and risk factors remain to be clarified.