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Contemporary Management of Alopecia: A Systematic Review and Meta-analysis for Surgeons

  • Review
  • Facial Surgery
  • Published:
Aesthetic Plastic Surgery Aims and scope Submit manuscript

Abstract

Background

The decision of surgical approach for hair restoration often involves evaluation of the type of alopecia; however, the impact of surgical hair restoration from existing techniques in specific population subsets has not been comprehensively investigated.

Objectives

The authors sought to systematically review the literature on micrografts, minigrafts, mini-micrografts, tissue grafts, tissue flaps and expanders, as well as evaluate graft survival and satisfaction within specific populations in a meta-analysis.

Methods

PubMed and Scopus literature searches between 1980 and 2018 yielded 57 articles for systematic review and 34 articles for meta-analysis. Study design, mean patient age and gender, patient alopecia type, surgical hair restoration technique, number of treatment areas, mean follow-up, graft survival rate and satisfaction rate were extracted from each study, and a meta-analysis was performed.

Results

The pooled rates of graft survival were 84.98% (95% CI 78.90–91.06) using micrografts and 93.11% (95% CI 91.93–94.29) using micrografts and minigrafts in nonscarring alopecia patients, as well as 88.66% (95% CI 80.12–97.20) using micrografts and 86.25% (95% CI 74.00–98.50) using micrografts and minigrafts in scarring alopecia patients. The pooled rates of satisfaction were 89.70% (95% CI 82.64–96.76) using micrografts and 97.00% (95% CI 92.48–100.0) using micrografts and minigrafts in nonscarring alopecia patients, as well as 97.80% (95% CI 94.59–100.0) using micrografts and 88.70% (95% CI 66.49–100.0) using micrografts and minigrafts in scarring alopecia patients. Dot plots depict rates of graft survival rate from micrografts and satisfaction from micrografts and minigrafts.

Conclusion

Surgical hair restoration for nonscarring and scarring alopecia yields high graft survival and satisfaction rates.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

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References

  1. National Library of Medicine (US). Genetics Home Reference [Internet]. Bethesda (MD): The Library; 2019 Mar 19. Androgenetic alopecia; [reviewed 2015 Aug; cited 2019 Jan 30]; [about 6 screens]. https://ghr.nlm.nih.gov/condition/androgenetic-alopecia. Accessed 15 Mar 2019

  2. Rhodes T, Girman CJ, Savin RC et al (1998) Prevalence of male pattern hair loss in 18–49 year old men. Dermatol Surg 24:1330–1332

    CAS  PubMed  Google Scholar 

  3. Qi J, Garza LA (2014) An overview of alopecias. Cold Spring Harbor Perspect Med 4(3):a013615

    Article  CAS  Google Scholar 

  4. Han SH, Byun JW, Lee WS et al (2012) Quality of life assessment in male patients with androgenetic alopecia: result of a prospective, multicenter study. Ann Dermatol 24(3):311–318

    Article  PubMed  PubMed Central  Google Scholar 

  5. Passchier J, Erdman J, Hammiche F, Erdman RA (2016) Androgenetic alopecia: stress of discovery. Psychol Rep 98(1):226–228

    Article  Google Scholar 

  6. Rossi A, Calvieri S (2014) Treatment for alopecia. G Ital Dermatol Venereol 149(1):103–106

    CAS  PubMed  Google Scholar 

  7. Adil A, Godwin M (2017) The effectiveness of treatments for androgenetic alopecia: a systematic review and meta-analysis. J Am Acad Dermatol 77(1):136–141

    Article  PubMed  Google Scholar 

  8. Iorizzo M, Tosti A (2015) Treatments options for alopecia. Expert Opin Pharmacother 16(15):2343–2354

    Article  PubMed  Google Scholar 

  9. Unger WP, Nordstrom RO (1995) Hair transplantation. In: Orentreich D, Orentreich N (eds) Androgenetic alopecia and its treatment: hair transplantation, 3rd edn. Marcel Dekker Inc., New York, pp 4–48

    Google Scholar 

  10. Orentreich N (1959) Autografts in alopecias and other selected dermatological conditions. Ann N Y Acad Sci 83(3):463–479

    Article  CAS  PubMed  Google Scholar 

  11. Adler SC, Rousso D (1999) Evaluation of past and present hair replacement techniques: aesthetic improvement, effectiveness, postoperative pain, and complications. Arch Fac Plast Surg 1(4):266–271

    Article  CAS  Google Scholar 

  12. International Society of Hair Restoration Surgery (2017) Practice census facts and figures [Internet]. http://www.ishrs.org/statistics-research.htm. Accessed 15 Mar 2019

  13. Lehmann A (2017) Hair transplantation using the crosspunch method. Case report of a patient suffering from androgenetic alopecia. Journal fur Asthetische Chirurgie 10(1):43–46

    Article  Google Scholar 

  14. Mohebbipour LA, Mirmohammadi R, Rezaei Bana M, Manoochehri S (2015) Hair follicles are viable after delayed FUE procedure. J Cosmet Laser Therapy 17(6):353–354

    Article  Google Scholar 

  15. Nilforoushzadeh MA (2015) Evaluating the success rate of follicular unit hair transplantation (FUT) technique in patients with gray hair. J Isfahan Med School 33(356):1820–1828

    Google Scholar 

  16. Palmieri B, Griselli G, D’ugo A, Palmieri G, Salti G (2000) Evaluation of polyamide synthetic hair. A long-term clinical study. Panminerva Med 42(1):49–53

    CAS  PubMed  Google Scholar 

  17. Serdev N, Erme AM D, Hercogova J et al (2015) Polyamide hair implant (biofibre®): evaluation of efficacy and safety in a group of 133 patients. J Biol Regul Homeost Agents 29:103–109

    CAS  PubMed  Google Scholar 

  18. Wang JP, Fan JC, Chai JK (2009) The treatment of cicatricial alopecia after burn with the technique of synchronously perforating and transplanting hair follicular-units. Chin J Burns 25(6):411–414

    Google Scholar 

  19. Wang J, Fan J (2002) Dense-packing hair grafting technique for restoration of cicatricial alopecia. Chin J Plast Surg 18(4):219–220

    CAS  Google Scholar 

  20. Lei J, Hou C, Duan P, Hao Z, Zhai Y, Meng Y (2015) Clinical application of modified skin soft tissue expansion in early repair of devastating wound on the head due to electrical burn. Chin J Burns 31(6):406–409

    Google Scholar 

  21. Fan J, Yang P (1997) Aesthetic reconstruction of burn alopecia by using expanded hair-bearing scalp flaps. Aesthet Plast Surg 21(6):440–444

    Article  CAS  Google Scholar 

  22. Huang S-R, Li X-Y, Wang H, Lin Y-D (2008) Scalp soft tissue expansion in combination with skin flap and hair transplantation for cicatricial alopecia with large area in 36 cases. J Clin Rehabil Tissue Eng Res 12(31):6137–6140

    Google Scholar 

  23. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6(7):e1000097

    Article  PubMed  PubMed Central  Google Scholar 

  24. Ahmad M (2009) Patient satisfaction in hair transplant surgery. J Pak Assoc Dermatol 19:9–12

    Google Scholar 

  25. Chung J, Sim JH, Gye J et al (2012) Successful hair transplantation for treatment of acquired temporal triangular alopecia. Dermatol Surg 38(8):1404–1406

    Article  CAS  PubMed  Google Scholar 

  26. Lee SJ, Lee HJ, Hwang SJ, Jun JB, Chung SL, Kim JC (2001) Evaluation of survival rate after follicular unit transplantation using the KNU implanter. Dermatol Surg 27(8):716–720

    CAS  PubMed  Google Scholar 

  27. Lee W, Lee S, Na G, Kim D, Kim M, Kim J (2006) Survival rate according to grafted density of Korean one-hair follicular units with a hair transplant implanter: experience with four patients. Dermatol Surg 32(6):815–818

    CAS  PubMed  Google Scholar 

  28. Lee YR, Lee SJ, Kim JC, Ogawa H (2006) Hair restoration surgery in patients with pubic atrichosis or hypotrichosis: review of technique and clinical consideration of 507 cases. Dermatol Surg 32(11):1327–1335

    CAS  PubMed  Google Scholar 

  29. Nakatsui T, Wong J, Groot D (2008) Survival of densely packed follicular unit grafts using the lateral slit technique. Dermatol Surg 34(8):1016–1025

    CAS  PubMed  Google Scholar 

  30. Seager DJ (1997) Micrograft size and subsequent survival. Dermatol Surg 23(9):757–762

    Article  CAS  PubMed  Google Scholar 

  31. Shah SA (2005) Functional outcomes of single follicular hair graft technique. J Coll Physicians Surgeons Pak 15(6):349–352

    Google Scholar 

  32. Shin D, Kim DY, Park JM (2015) Microstrip technique in follicular unit extraction. Dermatol Ther 28(5):269–270

    Article  CAS  PubMed  Google Scholar 

  33. Umar S (2016) Body hair transplant by follicular unit extraction: my experience with 122 patients. Aesthet Surg J 36(10):1101–1110

    Article  PubMed  PubMed Central  Google Scholar 

  34. Umar S (2015) Use of nape and peri-auricular hair by follicular unit extraction to create soft hairlines and temples: my experience with 128 patients. Aesthet Surg J 35(8):903–909

    Article  PubMed  Google Scholar 

  35. Umar S (2011) Hair transplantation in patients with inadequate head donor supply using nonhead hair: report of 3 cases. Ann Plast Surg 67(4):332–335

    Article  CAS  PubMed  Google Scholar 

  36. Barankin B, Taher M, Wasel N (2005) Successful hair transplant of eyebrow alopecia areata. J Cutan Med Surg 9(4):162–164

    Article  PubMed  Google Scholar 

  37. Barrera A (2003) Advances in aesthetic hair restoration. Aesthet Surg J 23(4):259–264

    Article  PubMed  Google Scholar 

  38. Barrera A (1997) Micrograft and minigraft megasession hair transplantation results after a single session. Plast Reconstr Surg 100(6):1524–1530

    Article  CAS  PubMed  Google Scholar 

  39. Barrera A (1997) Micrograft and minigraft megasession hair transplantation: review of 100 consecutive cases. Aesthet Surg J 17(3):165–169

    Article  CAS  PubMed  Google Scholar 

  40. Baser NT, Cigsar B, Akbuga UB, Terzioglu A, Aslan G (2006) Follicular unit transplantation for male-pattern hair loss: evaluation of 120 patients. J Plast Reconstr Aesthet Surg 59(11):1162–1169

    Article  Google Scholar 

  41. Ozcelik D (2005) Extensive traction alopecia attributable to ponytail hairstyle and its treatment with hair transplantation. Aesthet Plast Surg 29(4):325–327

    Article  Google Scholar 

  42. Toscani M, Fioramont P, Rusciani A, Scuderi N (2008) Hair transplantation to restore pubic area. Dermatol Surg 34(2):280–282

    Article  CAS  PubMed  Google Scholar 

  43. Yang CC (2003) Calvitron automated hair transplant system in alopecia treatment: a case report. Kaohsiung J Med Sci 19(9):470–474

    Article  PubMed  Google Scholar 

  44. Ho C, Nguyen Q, Lask G, Lowe N (1995) Mini-slit graft hair transplantation using the ultrapulse carbon dioxide laser handpiece. Dermatol Surg 21(12):1056–1059

    Article  CAS  PubMed  Google Scholar 

  45. Khalid K, Tarar MN, Mahmood F, Malik FS (2008) Scalp as a donor site for split thickness skin grafts. J Ayub Med Coll Abbottabad 20:66–69

    PubMed  Google Scholar 

  46. Chen HC, Mardini S, Santamaria E (2003) Long-term follow-up and unusual findings after microvascular transfer of hair-bearing skin for pubic hair restoration. Ann Plast Surg 51(6):627–629

    Article  PubMed  Google Scholar 

  47. Akdag O, Evin N, Karamese M, Tosun Z (2018) Camouflaging cleft lip scar using follicular unit extraction transplantation combined with autologous fat grafting. Plast Reconstr Surg 141(1):148–151

    Article  CAS  PubMed  Google Scholar 

  48. Gho CG, Neumann HA (2011) Improved hair restoration method for burns. Burns 37(3):427–433

    Article  PubMed  Google Scholar 

  49. Goldman GD (2001) Eyebrow transplantation. Dermatol Surg 27(4):352–354

    CAS  PubMed  Google Scholar 

  50. Jung S, Oh SJ, Hoon KS (2013) Hair follicle transplantation on scar tissue. J Craniofac Surg 24(4):1239–1241

    Article  PubMed  Google Scholar 

  51. Kasai Y, Igawa H, Abe N et al (2017) Successful follicular unit extraction hair transplant for bald area after skin graft. J Plast Reconstr Aesthet Surg Open 2017(13):71–76

    Google Scholar 

  52. Moreno-Arias GA, Camps-Fresneda A (1999) Hair grafting in postburn alopecia. Dermatol Surg 25(5):412–414

    Article  CAS  PubMed  Google Scholar 

  53. Woods R, Campbell AW (2004) Chest hair micrografts display extended growth in scalp tissue: a case report. Br J Plast Surg 57(8):789–791

    Article  PubMed  Google Scholar 

  54. Emsen IM (2008) The use of micrografts and minigrafts together with advancement of temporalis fascia and its periosteum on the treatment of burn alopecia. J Craniofac Surg 19(4):907–909

    Article  PubMed  Google Scholar 

  55. Levesque AY, Schalet BJ, Dolph JL (2011) Beard reconstruction using hair grafts in a free flap. Can J Plast Surg 19(4):151–152

    Article  PubMed  PubMed Central  Google Scholar 

  56. Santiago M, Pérez-Rangel R, D’Ugo A et al (2007) Artificial hair fiber restoration in the treatment of scalp scars. Dermatol Surg 33(1):35–44

    CAS  PubMed  Google Scholar 

  57. Donovan J (2012) Lichen planopilaris after hair transplantation: report of 17 cases. Dermatol Surg 38(12):1998–2004

    Article  CAS  PubMed  Google Scholar 

  58. Callender VD, Lawson C, Onwudiwe OC (2014) Hair transplantation in the surgical treatment of central centrifugal cicatricial alopecia. Dermatol Surg 40(10):1125–1131

    Article  CAS  PubMed  Google Scholar 

  59. MacLennan SE, Kitzmiller WJ, Mertens D, Warden GD, Neale HW (1998) Scalp autografts and hair transfer to the face in the burned child. Plast Reconstr Surg 102(6):1865–1868

    Article  CAS  PubMed  Google Scholar 

  60. Tenna S, Brunetti B, Aveta A, Poccia I, Persichetti P (2013) Scalp reconstruction with superficial temporal artery island flap: clinical experience on 30 consecutive cases. J Plast Reconstr Aesthet Surg 66(5):660–666

    Article  PubMed  Google Scholar 

  61. Datubo-Brown DD, Khalid KN, Levick PL (1994) Tissue-expanded visor flap in burn surgery. Ann Plast Surg 32(2):205–208

    Article  CAS  PubMed  Google Scholar 

  62. Drissi HQ, Nassih M, Rzin A, Jidal B (2007) Skin expansion in cicatricial alopecia of the scalp: 18 cases. Rev Stomatol Chir Maxillofac 108(5):411–418

    Article  Google Scholar 

  63. Fan J, Liu L, Tian J, Gan C, Lei M (2009) The expanded “flying-wings” scalp flap for aesthetic hemiscalp alopecia reconstruction in children. Aesthet Plast Surg 33(3):361–365

    Article  Google Scholar 

  64. Guzey S, Alhan D, Şahin I, Aykan A, Eski M, Nişancı M (2015) Our experiences on the reconstruction of lateral scalp burn alopecia with tissue expanders. Burns 41(3):631–637

    Article  PubMed  Google Scholar 

  65. Chen H, Cheng H, Shen H et al (2017) Scalp soft tissue expansion combined with follicular unit extraction for postburn cicatricial alopecia: a single center experience of 48 patients. Int J Clin Exp Med 10(1):774–780

    Google Scholar 

  66. Oh SJ, Koh SH, Lee JW, Jang YC (2010) Expanded flap and hair follicle transplantation for reconstruction of postburn scalp alopecia. J Craniofac Surg 21(6):1737–1740

    Article  PubMed  Google Scholar 

  67. Kim JC, Hadlock T, Varvares MA, Cheney ML (2001) Hair-bearing temporoparietal fascial flap reconstruction of upper lip and scalp defects. Arch Fac Plast Surg 3(3):170–177

    Article  CAS  Google Scholar 

  68. Kolasiñski J, Kolenda M (2003) Algorithm of hair restoration surgery in children. Plast Reconstr Surg 112(2):412–422

    Article  PubMed  Google Scholar 

  69. Motamed S, Davami B (2005) Eyebrow reconstruction following burn injury. Burns 31(4):495–499

    Article  CAS  PubMed  Google Scholar 

  70. Pensler JM, Dillon B, Parry SW (1985) Reconstruction of the eyebrow in the pediatric burn patient. Plast Reconstr Surg 76(3):434–440

    Article  CAS  PubMed  Google Scholar 

  71. Frechet P (1993) Scalp extension. J Dermatol Surg Oncol 19(7):616–622

    Article  CAS  PubMed  Google Scholar 

  72. Nordström REA, Raposio E (1999) Scalp extension—a quantitative study. Dermatol Surg 25(1):30–33. https://doi.org/10.1046/j.1524-4725.1999.08063.x

    Article  PubMed  Google Scholar 

  73. Jeong S-H, Koo S-H, Han S-K, Kim W-K (2010) An algorithmic approach for reconstruction of burn alopecia. Ann Plast Surg 65(3):330–337

    Article  CAS  PubMed  Google Scholar 

  74. Rousso DE, Kim SW (2014) A review of medical and surgical treatment options for androgenetic alopecia. JAMA Fac Plast Surg 16(6):444–450

    Article  Google Scholar 

  75. Vogel JE, Jimenez F, Cole J et al (2013) Hair restoration surgery: the state of the art. Aesthet Surg J 33(1):128–151

    Article  PubMed  Google Scholar 

  76. Uebel CO (2002) Refining hair restoration technique. Aesthet Surg J 22(2):181–183

    Article  PubMed  Google Scholar 

  77. Uebel CO (2011) Micrograft and minigraft megasessions in hair transplantation: current techniques and future directions. In: Nahai F (ed) The art of aesthetic surgery: principles & techniques, 2nd edn. Quality Medical Publishing, St Louis

    Google Scholar 

  78. Uebel CO (1991) Micrografts and minigrafts: a new approach for baldness surgery. Ann Plast Surg 27(5):476–487

    Article  CAS  PubMed  Google Scholar 

  79. Uebel CO (2007) Correcting hairline deformities after facial rejuvenation. Aesthet Surg J 27(4):459–465

    Article  CAS  PubMed  Google Scholar 

  80. Higgins JP, Altman DG, Gøtzsche PC et al (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928

    Article  PubMed  PubMed Central  Google Scholar 

  81. Murad MH, Asi N, Alsawas M et al (2016) New evidence pyramid. Evid Based Med 21:125–127

    Article  PubMed  PubMed Central  Google Scholar 

  82. Murad MH, Sultan S, Haffar S et al (2018) Methodological quality and synthesis of case series and case reports. BMJ Evid Based Med 23:60–63

    Article  PubMed  PubMed Central  Google Scholar 

  83. Murad MH (2017) Clinical practice guidelines: a primer on development and dissemination. Mayo Clin Proc 92:423–433

    Article  PubMed  Google Scholar 

  84. Gupta AK, Mays RR, Dotzert MS, Versteeg SG, Shear NH, Piguet V (2018) Efficacy of non-surgical treatments for androgenetic alopecia: a systematic review and network meta-analysis. J Eur Acad Dermatol Venereol 32(12):2112–2125

    Article  CAS  PubMed  Google Scholar 

  85. Dufner-Almeida LG, Cruz DBD, Mingroni Netto RC, Batissoco AC, Oiticica J, Salazar-Silva R (2019) Stem-cell therapy for hearing loss: are we there yet? Braz J Otorhinolaryngol 85(4):520–529

    Article  PubMed  Google Scholar 

  86. Giordano S, Romeo M, Lankinen P (2017) Platelet-rich plasma for androgenetic alopecia: does it work? Evidence from meta analysis. J Cosmet Dermatol 16(3):374–381

    Article  PubMed  Google Scholar 

  87. Giordano S, Romeo M, di Summa P, Salval A, Lankinen P (2018) A meta-analysis on evidence of platelet-rich plasma for androgenetic alopecia. Int J Trichol 10(1):1–10

    Article  Google Scholar 

  88. Badran KW, Sand JP (2018) Platelet-rich plasma for hair loss: review of methods and results. Fac Plast Surg Clin N Am 26(4):469–485

    Article  Google Scholar 

  89. Rose PT (2018) Advances in hair restoration. Dermatol Clin 36(1):57–62

    Article  CAS  PubMed  Google Scholar 

  90. Uebel CO, Da Silva JB, Cantarelli D, Martins P (2006) The role of platelet plasma growth factors in male pattern baldness surgery. Plast Reconstr Surg 118(6):1458–1466

    Article  CAS  PubMed  Google Scholar 

  91. Okereke UR, Simmons A, Callender VD (2019) Current and emerging treatment strategies for hair loss in women of color. Int J Womens Dermatol 5(1):37–45

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  92. Bared A, Epstein JS (2019) Hair transplantation techniques for the transgender patient. Fac Plast Surg Clin N Am 27(2):227–232

    Article  Google Scholar 

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Authors and Affiliations

  1. Keck School of Medicine of USC, University of Southern California, 1510 San Pablo Street, Suite 415, Los Angeles, CA, 90033, USA

    Jacqueline Stoneburner & Orr Shauly

  2. Department of Plastic and Reconstructive Surgery, Keck Hospital of USC, University of Southern California, 1510 San Pablo Street, Suite 415, Los Angeles, CA, 90033, USA

    Joseph Carey, Ketan M. Patel & Daniel J. Gould

  3. Marina Plastic Surgery, Marina Plastic Surgery Associates, 4644 Lincoln Blvd., Suite 552, Marina Del Rey, CA, 90292, USA

    W. Grant Stevens

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  1. Jacqueline Stoneburner
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Stoneburner, J., Shauly, O., Carey, J. et al. Contemporary Management of Alopecia: A Systematic Review and Meta-analysis for Surgeons. Aesth Plast Surg 44, 97–113 (2020). https://doi.org/10.1007/s00266-019-01529-9

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