Advances in Hair Restoration and Hair Transplantation

Understanding patient history, utilising trichoscopy, and considering various treatment options are crucial steps in effective hair restoration.

L-R: Dr Avinash Agrawal, Dr Viral Desai, Dr Vinay Chouksey.

Advances in aesthetic hair restoration and hair transplant have leaped into the realm of regenerative medicine, heralding a promising future. Every day, new combinations and molecules are launched in the industry, making it challenging to keep up with these innovations. Despite this ever-changing landscape, some time-tested compositions, such as minoxidil and finasteride, continue to hold their ground in the industry. These drugs serve as the gold standard and the first line of action against hair loss. However, it is essential to acknowledge that these FDA-approved treatments are not without their side effects.

While some of the side effects include excessive hair growth, beard growth, irritation, dermatitis, and dryness, these drugs also pose risks of erectile dysfunction, decreased libido, impotency, rashes, swelling of the face and lips, breast tenderness, and more. Additionally, regular treatments have a non-response rate ranging from 35 to 48 per cent, which is relatively high. It is common to observe a high dropout rate and several complications associated with these treatments, with finasteride known to have some longterm side effects.

Importance of noting patient history

Understanding the patient and identifying their hair loss problem is crucial for devising an effective treatment plan. Questions about the timeline of hair loss, its onset, progression rate, and current grade are essential. Additionally, considering the patient’s genetic history plays a vital role in their treatment approach.

Minoxidil and finasteride are widely available over the counter, and patients’ usage and frequency of these products should be carefully assessed. Dr Viral Desai, Cosmetic & Plastic Surgeon, Co-Founder & Medical Director, DHI India; and Medical Director, CPLSS, Desai Hospitals and Sarla Hospitals; and Founder & Medical Director, Skin Vibes Clinic, emphasises the significance of considering various factors such as age, alcohol intake, smoking, lifestyle, stress, exercise habits, exposure to pollution and sun, and levels of calcium, iron, vitamin B, and D, as they can contribute to hair loss. In some cases, oral medication for nutrition may be necessary to stabilise the condition before starting the hair restoration process.

These factors become even more crucial when dealing with patients with androgenic alopecia or male pattern hair loss, where both genetic and lifestyle factors are involved. Administering thyroid tests to check for imbalances and monitoring blood pressure before prescribing finasteride to men above 45 is essential.

For women, hormonal imbalances and vitamin deficiencies, particularly B3 and D, should be taken into account during the medical history assessment. Additionally, considering the prevalence of PCOS is vital in understanding the potential factors contributing to hair loss in female patients.

Trichoscopy

“Trichoscopy is a crucial tool in my practice, helping me identify various hair problems accurately,“ says Dr Avinash Agrawal, Director Partner, Acube Aesthetics Clinic. With trichoscopy, he can distinguish conditions like lichen from paternal hair loss, avoiding misdiagnoses. The 100x magnification provides comprehensive information about a patient’s hair, including texture, type, grade of hair fall, and scalp issues. This aids in efficient diagnosis and treatment planning.

Dr Desai takes an additional step by performing biopsies on many patients after trichoscopy. This post-trichoscopy biopsy helps detect issues like areata, which can lead to unresponsiveness to treatment. By identifying such cases beforehand, patients can avoid unnecessary expenses and procedures that might not be effective. Trichoscopy also assists in detecting over 10 per cent telogen, enabling stabilisation through appropriate medication.

Treatment options and procedures

Dr Agrawal prescribes Minoxidil to all patients above 60 years of age. “Patients with grade 3 or grade 4 hair loss require a transplant, and I would prescribe Finasteride only if they have a family history of hair loss. It is important to consider potential side effects.“

Dr Vinay Chouksey, Chief Hair Transplant Surgeon, Wow Cosmetology Centre, Juhu, and Richfeel Hairforever, says, “I don’t give minoxidil to all patients, but I use it liberally. Patients can become reliant on minoxidil but struggle with compliance. I try to avoid that situation. I prefer doing PRP and DST blockers and then starting my patients on finasteride. I am, however, cautious about who I administer finasteride to.“

Dr Agrawal, on the other hand, believes that Redensyl works better than minoxidil in many cases because it doesn’t cause dependency and delivers good results. He also considers RCP to be a promising molecule, administering it to patients who have shown good compliance.

While the market is flooded with various combinations, minoxidil works effectively on its own and remains a popular choice for monotherapy. The standard dosage is 2 % minoxidil for beard and 5% for both males and females, to be applied twice a day.

Minoxidil paired with finasteride yields positive outcomes, but finasteride should not be administered in women. Caution must be exercised at all times when using finasteride. Each individual’s situation is unique, and they should be treated accordingly.

Also, Procapil or capixyl combined serum is a beneficial treatment that can be applied at night.

The right application of minoxidil

Inappropriate application of minoxidil has been known to aggravate sinus or migraine attacks. The best way to apply it is on the crown area. Since it is an alcohol-based molecule, it may cause dryness and an itchy scalp. However, it is important not to scratch. Gently massage it onto the scalp, not the hair. Apply it two hours before sleeping. Avoid applying any oil before minoxidil, as it can create a barrier and hinder the medicine’s effectiveness. Use serum and conditioner twice daily for the best results.

Finasteride vs. Dutasteride

Starting dutasteride after two years of treatment is a good option. The standard dosage is 0.5 mg thrice weekly. Topical finasteride is a good alternative for those who refuse to take oral medication due to its known side effects. The standard dose for topical application is 0.25 mg. While Redensyl gives good results, it is worth noting that less than 3% concentration does not work, so keep that in mind when using the product.

The dosage of medications changes according to the patient’s requirement and compliance. However, do not solely rely on what the company tells you. Select the concentrations and combinations that work best for your patients. Molecules can be expensive, so the dosage must be charted with great care.

Oral Medication for Hair Loss

Dr Chouksey says, “Oral minoxidil is quite popular among women and mostly used by them. Women prefer pills because they are more conscious of their looks. And Oral minoxidil can avoid dry, flaky scalp and frizzy hair compared to topical application. In some cases, the lack of scalp inhibitors leads to failed results with topical minoxidil, where oral medication works best.

An enzyme called sulfonyl transferase exists in the scalp. When minoxidil comes in contact with this enzyme, Minoxidil sulfate is formed. This compound acts on the scalp and reduces hair loss. The starting dose can be 2.5 mg and a maximum of 5 mg, exceeding that is not advisable. ECG and blood pressure must be monitored for patients above 40. Happy patients are compliant patients, and it works vice versa too!

Nanoxidil, another option for minoxidil, has been launched globally but not yet available in India. It negates side effects like crystallisation, dryness, and frizzy hair. It is available in cream form and with aloe vera combinations, but the results are not as effective.

Low-level laser therapy

Dr Chouksey prefers using LLLT or cold lasers for patients allergic to minoxidil. It is a time-tested treatment with three to six months of downtime. Patients can perform it at home with 80 diodes and visit the clinic for a 270-diode laser treatment. He believes the laser helmet works better than a laser comb.

Dr Agrawal says, “A machine called Recosma uses combinations of laser, erbium, alexandrite, and diode lasers at a particular frequency to treat all three layers of the skin. It is used for plastic therapy and hair growth. It is a very expensive machine.“

Micro Injuries Mesotherapy and micro-needling with radiofrequency are all scalp injuries that cause inflammation and help jumpstart natural chemicals in the scalp, giving good results.

PRP and Mesotherapy

There are contradicting opinions of PRP vs. GFC among many doctors. While PRP post-hair transplantation gives good results, some doctors prefer GFC. One of the greatest advantages of GFC is that it requires less frequency, and cytosomal storms can be easily avoided with the process.

Dr Agrawal prefers doing micro-needling post- GFC. The follicles are 2 to 3 mm obliquely located and can be accessed by microneedles.

As for mesotherapy, it causes a lot of trauma and blood, and sometimes patients come back with problems. However, mesotherapy with micro-needling to penetrate the product without extra trauma gets the nod of the doctors. Dutasteride and, in some cases, peptides have worked as monotherapy agents.

Dr Chouksey says, “Among peptides, qr678 has made my patients happy. It increases the anchoring and reduces hair fall.“

Epigenine biochanin, when used as a serum, also works well. The greatest advantage is that it has no side effects.

Other treatment options

Auxina tricogena combined with minoxidil works well with patients with estrogen pathways but is less used in male pattern baldness. It acts as an estrogen stimulator and reduces hair loss. Seventeen beta-estradiol is another application product available in the market that has proven useful for many patients.

Prostaglandins, PGF2, promote hair growth. It works on eyelashes, and more research is being done on its effect on head hair. The results are short-lived and cost high for this treatment, so its popularity is low in the industry.

Dr Agrawal says, “Adipose-derived stem cells FUE are not great. FUT, the process of transplant along with fat cells, has a much higher survival rate and yields better results.“

Dr Desai also specifies that nano fat has less SVF amount but a high amount of natural oils. It can be used for preventative purposes, and the results are much better with regenerative procedures. Mechanical SVF is a minor surgical procedure that provides rejuvenating effects to the patient.

The next big step

Regenerative medicine and nutritional therapy are the upcoming heroes in aesthetic medicine. Exosomes are eagerly awaited by many in the industry. Exosomal cells are collected from donated amniotic material. There are other regenerative options, such as beta-carotene; however, exosomes are much awaited in India. They promise no side effects and good results.

Dr Desai says, “Regenerative cells in fat are 4 or 5 times higher than placenta, amniotic, bone marrow, or ectoderm.”

Robotic hair transplant and other big ‘NO’

Humans are born with approximately 120 hair per sq cm. Any surgeon can do a minimum of 35 to a maximum of 70 grafts per sq cm, which is a close approximation. Robotic hair transplant machines can perform the procedure; however, there is only one machine available in India, operating in Ahmedabad. A new robotic machine (version 3) is now available and can perform implants, but the yield from robotic surgery is less, the cost is higher, and the benefits are minimal. Therefore, it is not popular in the industry.

Botulinum toxin is sometimes used to deal with hair loss, but it is a muscle relaxant. It is not very effective in the long run and, therefore, not preferred by plastic surgeons.

Similarly, as appealing as the concept of bio-fibres may seem, it is not FDA-approved and poses a huge risk. It might be an option for burn victims or patients with scarring alopecia, but these fibres are made of nylon. They may cause pain, inflammation, scars, and infection, making them not advisable. Besides, the procedure is not FDA-approved.

Counselling of hair loss patients

Hair products and medicines used in hair loss treatment are a lifetime requirement to maintain hair health. Patients must understand that. Some counselling is required to help them understand that if mediation is stopped, so will the growth. Therefore, in many cases, doctors administer drugs that give rapid results to make patients happy about the progress. A happy patient is a compliant patient, and there are higher chances of compliance if patients are happy to see the results.

Similarly, 15 days or a month of medication must be administered to see if any side effects occur in the patient or if the patient is responding well to medication before leading them to transplant. It is a good practice and keeps patients happy.

It is also worth mentioning that 2 or 3 sessions of transplant might be required in 5 years of time, and medicines are important to maintain the hairline after transplantation.

(The above insights were gathered from a panel discussion at the recently concluded Aesthetic Medicine Conference in Mumbai.)