PRP-HAIR GRAFT 2008
HAIR RESTORATION SURGERY FOR ANDROGENIC ALOPECIA WITH AUTOLOGOUS PLATELET RICH PLASMA (PRP): INFORMATION FOR HAIR RESTORATION DOCTORS
Marx, Pietzrak of the United States and Du Toit of Stellenbosch, have alluded to the platelet growth factor induced healing properties of autologous platelet-rich plasma (PRP). Currently, PRP is undergoing extensive investigation in clinical trials in cardiovascular, burn, cosmetic, orthopaedic and maxillo-facial surgery. Product quantification, blood collection systems, centrifugation, is critically important to ensure optimal yields of platelets and GF content ( PDGF,TGF, EGF and VEGF). In South Africa, REGENLAB PRP, has consistently proven to be the leaders in platelet-derived GF, rendering the best platelet yields and GF analysis, cell therapy and cellular regeneration. A recent leading publication in VOX Sanguinis 2008, from academic unit in Europe, where 6 products were assessed, supports this observation.
Carlos Uebel, a Brazilian plastic surgeon, and author of a book on hair transplantation, has demonstrated the encouraging trophic effects of PRP on the density, growth and success of hair transplants. Bernstein et al from the United States, has also made valuable contributions in the application of hair transplantation and stressed need for good technique. Surgical hair restoration by follicular transplantation is relevant as a treatment for male hair-pattern hair loss for more than 40 years. Surgical technique has improved, and so has the results of autogenous hair transplantation. However, the problems of autologous fat transplantation, characterised by post-procedural and interval graft atrophy seem to mirror some of hair graft-loss after hair transplantation. This may well be related to suboptimal GF at the site of engraftment in the recipient field, that impairs “take” of the graft. Unfavourable outcomes, poor growth, reduced micrograft survival rates, post-transplantation may be related to one or more of the following factors:
- Technical errors ( ignoring critical fine anatomy as shown in the gallery)
- Poor planning
- Complications ( disregard for established surgical principles)
- Recipient bed failure ( reduced scalp laxity, fibroblast senescence, scarring, dermal solar damage, reduced vascularity)
- Donor site failure ( poor microdissection technique)
- Iatrogenic trauma to grafts / rough graft handling ( ie graft injury)
- Reduced follicle yield ( unskilled technician, or use of outdated harvesting technique). Poor knowledge of the anatomy of the hair follicle.
Follicular unit transplantation outcomes may be increased by the correct application of PRP.
- Donor site pre-treatment with PRP ( purpose is to provide platelet cell therapy and platelet-derived growth factors, both of which are key elements in wound healing).
- Recipient site pre-treatment with PRP ( this seems to be an important factor affecting graft growth and survival rates).
- Optimal use of intra-operative PRP and platelet-derived growth factors, in and around the graft
- Graft emersion in PRP ( “ soaking the graft in the PRP gel”)
Restorative hair transplantation outcomes may well be improved by the application of accurately quantified PRP, which up to date has bugged studies. BOLANDCELL acknowledges that TGF-beta may be a complicating factor in the etiology of hairloss, but that is not a deterrent to the use of PRP in hair transplantation, as the results of Carlos Uebel, from Brazil suggest. Other areas where PRP has had positive effects, is admixture with autologous micro-fat transfer for facial rejuvenation and augmentation of facial lines and wrinkles.
ILLUSTRATION GALLERY: HISTOLOGY, MICRO-ANATOMY, HAIR SHAFT RELATIONSHIPS, TISSUE CULTURE AND CELL BIOLOGY, AUTOLOGOUS PLATELET-RICH PLASMA (PRP), RELEVANT TO HAIR TRANSPLANTATION.
Figure 1: Human hair follicle showing relationship to branching sebaceous glands. This anatomical relationship is important during harvest of the follicle prior to transplantation. Verhoef x 40.
Figure 2: Human hair. Showing collagen and fibroblasts in relationship to the apex of the follicle. Note surrounding matrix and connective tissue. Verhoef x 40
Figure 3: Human hair. Masson Trichrome histological stain showing sebaceous glands in relationship to the apex of the hair follicle. X 40. Careful excision is important during harvesting of the follicle and adjacent structures.
Figure 4: Human hair. Lateral relationships of the hair follicle showing fibroblast sheath and dense attachments via collagen and fibrous bands. Note deposition of elastin fibres in relationship to the hair follicle. Verhoef x 60. Avoid excessive trauma and handling during harvesting of the hair follicle.
Figure 5: Human hair. Hair follicle unit. Note shaft, lateral dense connective tissue and relationships of the sebaceous glands. Verhoef x 40. Very careful attention to fine detail and the anatomy of the hair follicle is needed during harvesting of the donor organ prior to transfer to the frontal scalp ( recipient site).
Figure 6: PRP is produced by centrifugation of anticoagulated venous blood taken from the medial cubital fore-arm vein. The centrifuge must be well balanced and the buffy coat must be clearly visible. This is visible in the left tube. This layer contains neutrophils and platelets. Two spins may be necessary to obtain a good result. REGENLAB PRP, available in South Africa renders the best yields of platelets, and platelet derived growth factors ( PDGF, TGF, EGF, FGF, VEGF). For quantification data read ref by Muzzucco et al , 2008. Grafts can be soaked in the autologous platelet-rich gel prior to engraftment. Local infiltration of the surrounding scalp with PRP may be important to deliver the platelet-derived GF to the recipient transplantation site.
Figure 7 : PRP primed primary cell culture ex vivo and showing adipose derived-mesenchymal stem cells. Note adjacent apoptotic cell. The mesenchymal derived fibroblasts as seen in ex vivo TC are critically important after hair follicle engraftment. This is one of the sites that GF work and enhance wound healing.
Figure 8: REGENLAB PRP generated 3D scaffold of human fibroblasts ex vivo that are critical for the formation of the ECM. Note branching of the fibroblasts and cell-cell interaction x 25,000.
Figure 9 : Fibroblasts in TC ex vivo showing locomotion and crawling of fibroblasts in REGEN PRP enriched medium. These cell lines are critical for engraftment of transplanted hair follicles.
BOLANDCELL ACADEMIC REFERENCES RELEVANT TO AUTOGENOUS HAIR TRANSPLANTATION AND PLATELET RICH PLASMA (PRP)
Du Toit DF et al. Soft and hard-tissue augmentation with platelet-rich plasma: Tissue culture dynamics, regeneration and molecular biology perspective. International Journal of Shoulder Surgery. 2007, 1: 64-73.
Du Toit DF et al. Shoulder surgeon and autologous cellular regeneration (ACR)-from bench to bed; Part 1-the link between the human fibroblast, connective tissue disorders and shoulder. International Journal of Shoulder Surgery 2007;2:
Junqueira LC, Carneiro J. Basic Histology. Text and Atlas. Lange, New York, 2003, 95-1259 ( Good histology reference).
Kierszenbaum AL. Histology and cell biology. An introduction to pathology, Mosby, St Louis, 2002: 106-108 ( Excellent overview on hair histology).
Marx RE, Garg AK. Dental and Craniofacial applications of platelet-rich plasma. Quintessence books, Chicago, 2005:1-154. (Pioneer of PRP treatment in maxillo-facial surgery).
Kumar V, Cotran RS, Robbins SL. Robbins Basic Pathology. 7th edit., Saunders, Philadelphia, 2003: 74-75
Marx RE, Garg AK. Dental and Craniofacial applications of platelet-rich plasma. Quintessence books, Chicago, 2005:1-154
Eppley BL, Pietrzak WS, Blanton W. Platelet-rich plasma: A review of biology and applications in plastic surgery. Plast Reconstr Surg. 2006: 118:147E-159C.
Pietrzak WS, Eppley BL. Platelet-rich plasma. Biology and new technology. J Craniofacial Surg 16: 2005,1043-1054
Ebstein JS. Revision surgical hair restoration: repair of undesirable results. Plast Reconstruct Surg 1999: 104: 222-32
Pietrzak WS, Yuehuei H, Qian K, Harry AD, Ehrens CH. Platelet-Rich and Platelet poor plasma: Development of an animal model to evaluate hemostatic efficacy. Cranial Facial Surgery, 2007,18:559-566
12. Mazzucco L et al. Platelet rich plasma and platelet gel preparation using Plateltex®. Vox Sanguinis 2008: 1: 1-7.( see quantification data on REGENLAB PRP compared to other products).
13. Bernstein RM et al. The aesthetics of follicular transplantation. Dermatol Surg 1997: 23: 785-99
14. Greco JF et al. A “ crush study” review of micrograft survival. Dermatol Surg 1997: 23: 752-5
15. Bernstein RM et al. The art of repair in surgical hair restoration part 1: basic repair strategies. Dermatol Surg 2002 : 28: 783-94.
16. Hwang S et al. Does the recipient site influence the hair growth characteristics in hair transplantation. Dermatol Surg 2002: 28: 795-8.
Posted: 4 May 2008.
DISCLAIMER: BOLANDCELL does not provide treatment options or information. All clients must develop a sensible relationship with a medically qualified health care professional or specialist and to discuss treatment options, outcomes and side-effects.