- Email: [email protected]
Use of topical minoxidil as a possible adjunct to hair transplant surgery
Volume 16 Number 3, Part 2 March 1987 DISCUSSION Question. Do you agree that patients with baseline counts of about 200 indeterminate hairs in the I-inch target area represent good candidates for minoxidil treatment? Answer. I think you're going to see an earlier result in that group. You're picking the people who are going to show you the fastest results, not necessarily the only people who are likely to get a good result, but they're not going to have to be as patient as some of the others. Question. I'd like to ask each of you: If you were designing new protocols for topical minoxidil studies, would you pick the center of the balding vertex as your counting site?
Topical minoxidil for androgenetic alopecia
Answer. I would pick the edge of the balding area. That's where the response is first seen in the people I have worked with. Question. So you would measure the diameter of the balding area, but for doing counts, which may not be necessary in the future, you would pick the edge? Answer 1. I think we would see early statistical data better at the edge than at the center. Answer 2. Yes, that was my impression. I think it might be a more useful place to look, rather than the very center. Answer 3. We're actually demanding the most of the drug by going to the center of the vertex.
Use of topical minoxidil as a possible adjunct to hair transplant surgery A pilot study J. J. Kassimir, M.D. New York. NY Twelve patients, aged 21 to 60 years, with varying Hamilton classifications of androgenetic alopecia (male pattern baldness) were treated with a 3% solution of topical minoxidil. Therapy began 48 to 72 hours after hair transplant surgery. Two patients demonstrated hair growth in the grafts without the shedding that usually occurs 2 to 4 weeks after surgery. (In untreated patients after hair transplant surgery, regrowth begins 3 to 5 months after surgery, after the shedding period.) A review of the literature-and personal discussions with surgeons whose hair transplant experience spans 25 years-revealed no evidence of a similar report. In addition, two of the remaining 10 patients had regrowth <4 weeks after postsurgical telogen effluvium. Neither patient age nor number of grafts transplanted played a predictive role. The location of the operative procedure also failed to predict, or preclude, successful regrowth. Topical minoxidil may be an important adjunctive therapy during the recuperative period in patients who have undergone hair transplant surgery. Carefully controlled studies are needed to substantiate this preliminary observation. (J AM ACAD DERMATOL 1987;16:685-7.)
From the Department of Dermatology, New York University Medical Center. Reprint requests to: Dr. J. 1. Kassimir, 10 E. 88th St., New York,
NY 10028.
Since 1985 an estimated four million men and a number of women have undergone hair transplant surgery. perhaps the most common type of plastic surgery performed today. The use of punch
685
Journal of the American Academy of Dermatology
686 Kassimir
autografts in various alopecias and other dermatologic conditions was first described by Orentreich 1 in 1959. On the other hand, the use of autografts for the correction of traumatic alopecia dates to the latter part of the nineteenth century. Apparently it was first described by Davis in 1911. 2 In 1939 a Japanese dermatologist, Shoji Okuda, 3 described the use of 2 to 4 mm full-thickness "homografts" of hair-bearing skin for the correction of alopecia of the scalp, eyebrows, and moustache area. Two hundred patients, primarily with cicatricial alopecia, were treated successfully with this technique. What has distinguished the punch autograft technique of hair transplantation from rhinoplasty, blepharoplasty, rhytidectomy, and other forms of cosmetic surgery is the long lag between the operation itself and attainment of an acceptable cosmetic result. This lag has been the result of two limiting factors: (I) the maximum number of grafts that can be transplanted per session (between 50 and 100) and (2) the postoperative telogen effluvium, which usually occurs 2 to 4 weeks after transplantation. Although the hairs transplanted in this way appear to be growing, they are actually being extruded in a slow process that can be called "anagen loss." As a rule it is not until the twelfth to the sixteenth postoperative week-and on occasion not until the twentieth week-that new hair growth begins, and it is not until 9 months after the second transplant session (which takes place 6 weeks to 4 months after the first) that some cosmetic improvement is realized. Four transplantation sessions are typically required; on the most compressed schedule possible the fourth session is achieved no earlier than 9 Yz months after the first. Significant improvement (regrowth of the frontal hairline) cannot be attained in most patients until 2 full years after the last of these four standard transplant sessions. Clearly any method that shortens this "awkward period" would be welcome. METHODS Twelve healthy male volunteers, aged 21 to 60 years, who were undergoing the first hair transplant procedure participated in this open, noncontrolled pilot study. Each subject was given a complete physical examination, during which a detailed medical history and all
vital signs were recorded. Informed consent was obtained from all subjects, who were instructed not to use any topical medication other than the test drug during the study. Beginning 48 to 72 hours after surgery, each subject applied minoxidil 3% solution twice daily to the transplant area. Application was not begun earlier because of the high alcohol content of the medication and the possibility of increased systemic absorption through a fresh wound. Patients returned for postoperative observation 1 day after surgery and again I week later. When shedding occurred, and again when hair growth began, the patient made repeat visits to confirm these phenomena with the surgeon.
Transplant procedure Grafts measuring 4 mm in diameter were chosen for their hair yield per surface area. The donor area was infiltrated with a solution of 1% lidocaine (Xylocaine) with epinephrine. Saline solution was administered through a 30-gauge needle to increase tissue turgor. An electrically powered transplant punch (Bell hand engine) was used to harvest the grafts. Approximately 30 to 45 minutes elapsed between the harvesting and cleaning of the grafts and their insertion into the recipient areas. During this period the grafts were placed in roomtemperature saline solution. In nine patients the 4 mm grafts were inserted into 3.5 mm holes and in one patient into 3.25 mm holes. In the two remaining patients each graft was divided into four quadrants and each quadrant was inserted into a 1 mm hole. This latter technique not only permits the transplanting of individual follicles but it also refines the hairline to produce a more natural appearance. Four of the 12 patients (aged 34 to 43 years) received transplants in the vertex area. The number of grafts ranged between 40 and 75 per patient. The other eight patients (aged 21 to 60 years) received transplants in the frontal area. The number of grafts in this group ranged between 40 and 60 per patient (Table I). RESULTS
Two patients from this small study group (Nos. 8 and 10) demonstrated regrowth without telogen shedding. Both patients received transplants to the vertex area-50 and 40 grafts into recipient holes of 3.5 mm and 3.25 mm, respectively. Two other patients (Nos. 2 and 11) both of whom had ten 4 mm grafts subdivided into forty 1 mm sections and transplanted into I mm recipient frontal sites commenced visible growth on the twenty-eighth
Volume 16 Number 3, Part 2 March 1987
Minoxidil as adjunct to hair transplant surgery
687
Table I. Characteristics of patients and transplants Patient No.
I
1 2
3 4 5 6
7 8 9 10 11
12
Age (yr)
34 24 29 24 41 29 43 42 21 40 23 60
Telogen effiuvium
Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Yes
I
Transplant location
I
No. of grafts
Vertex Frontal Frontal Frontal Frontal Frontal Vertex Vertex Frontal Vertex Frontal Frontal
and thirtieth days after the initial shedding period-far sooner than the typical 12 to 16 weeks. The remaining eight patients showed regrowth between the twelfth and sixteenth weeks. DISCUSSION
From this small noncontrolled study it is not possible to generalize about the effect of topical minoxidil solution on postoperative shedding and regrowth after hair transplantation. Neither can a statistical correlation be made regarding the effects of age, location of transplants, number of grafts, and graft size versus recipient hole size on the outcome. However, it is of considerable interest that only four of the 12 patients underwent procedures in the vertex area, and two of these (patients 8 and 10) had no postoperative telogen shedding phase. An extensive literature search, as well as personal communications with surgeons whose experience with hair transplantation spans 25 years, has yielded no report of immediate hair growth without the initial telogen effluvium after hair transplantation. It is also noteworthy that two additional patients commenced visible hair regrowth on the twentyeighth and thirtieth days after the initial shedding period-far sooner than the typical interval of 12 to 20 weeks. In conclusion, topical minoxidil may be an appropriate adjunct to hair transplant surgery. A larger, controlled study is needed to establish the reproducibility of these findings-namely that top-
60 40 60 60 55 50 75 50 40 40 40 50
I
Graft sbe/recipient hole size (mm)
4/3.5 111 4/3.5 4/3.5 4/3.5 4/3.5 4/3.5 4/3.5 4/3.5 4/3.25 111 4/3.5
ical minoxidil may eliminate posttransplant shedding and hasten the onset ofpostshedding regrowth in some cases. The role of factors such as patient age and the number, size, and location of transplanted grafts in predicting these effects also needs to be determined. REFERENCES 1. Orentreich N. Autografts in alopecias and other selected dermatologic conditions. Ann NY Acad Sci 1959;83:403. 2. Davis JS. Scalping accidents. Bull Johns Hopkins Hosp 1911 ;16:257. 3. Okuda S. The study of clinical experiments and hair transplantation. Jpn J Dennatol Urol 1939;Oct:537. Gennan Abstr: Klinische and experimentelle untersuchungen uber die transplantation von lebenden haaren. Jpn J Dennatol Urol 1939;46:135.
DISCUSSION
Question. Have you thought about pretreating the donor area or the recipient area with minoxidil or putting the grafts into minoxidil solution before transplantation? Answer. I did think about that. The reason I did not pretreat the donor area is that I did not want to risk making the surgical procedure more complicated by possibly inducing more bleeding. In the last few years there has been only one patient in whom I had to halt a surgical procedure at the beginning because of bleeding. He was taking a peripheral vasodilator. As far as putting the grafts into the minoxidil solution, that is a good idea. We might do one test procedure, but I would prefer to place the grafts into a solution that contains no alcohol or propylene glycol; another vehicle perhaps could be used.
Topical minoxidil for androgenetic alopecia
Answer. I would pick the edge of the balding area. That's where the response is first seen in the people I have worked with. Question. So you would measure the diameter of the balding area, but for doing counts, which may not be necessary in the future, you would pick the edge? Answer 1. I think we would see early statistical data better at the edge than at the center. Answer 2. Yes, that was my impression. I think it might be a more useful place to look, rather than the very center. Answer 3. We're actually demanding the most of the drug by going to the center of the vertex.
Use of topical minoxidil as a possible adjunct to hair transplant surgery A pilot study J. J. Kassimir, M.D. New York. NY Twelve patients, aged 21 to 60 years, with varying Hamilton classifications of androgenetic alopecia (male pattern baldness) were treated with a 3% solution of topical minoxidil. Therapy began 48 to 72 hours after hair transplant surgery. Two patients demonstrated hair growth in the grafts without the shedding that usually occurs 2 to 4 weeks after surgery. (In untreated patients after hair transplant surgery, regrowth begins 3 to 5 months after surgery, after the shedding period.) A review of the literature-and personal discussions with surgeons whose hair transplant experience spans 25 years-revealed no evidence of a similar report. In addition, two of the remaining 10 patients had regrowth <4 weeks after postsurgical telogen effluvium. Neither patient age nor number of grafts transplanted played a predictive role. The location of the operative procedure also failed to predict, or preclude, successful regrowth. Topical minoxidil may be an important adjunctive therapy during the recuperative period in patients who have undergone hair transplant surgery. Carefully controlled studies are needed to substantiate this preliminary observation. (J AM ACAD DERMATOL 1987;16:685-7.)
From the Department of Dermatology, New York University Medical Center. Reprint requests to: Dr. J. 1. Kassimir, 10 E. 88th St., New York,
NY 10028.
Since 1985 an estimated four million men and a number of women have undergone hair transplant surgery. perhaps the most common type of plastic surgery performed today. The use of punch
685
Journal of the American Academy of Dermatology
686 Kassimir
autografts in various alopecias and other dermatologic conditions was first described by Orentreich 1 in 1959. On the other hand, the use of autografts for the correction of traumatic alopecia dates to the latter part of the nineteenth century. Apparently it was first described by Davis in 1911. 2 In 1939 a Japanese dermatologist, Shoji Okuda, 3 described the use of 2 to 4 mm full-thickness "homografts" of hair-bearing skin for the correction of alopecia of the scalp, eyebrows, and moustache area. Two hundred patients, primarily with cicatricial alopecia, were treated successfully with this technique. What has distinguished the punch autograft technique of hair transplantation from rhinoplasty, blepharoplasty, rhytidectomy, and other forms of cosmetic surgery is the long lag between the operation itself and attainment of an acceptable cosmetic result. This lag has been the result of two limiting factors: (I) the maximum number of grafts that can be transplanted per session (between 50 and 100) and (2) the postoperative telogen effluvium, which usually occurs 2 to 4 weeks after transplantation. Although the hairs transplanted in this way appear to be growing, they are actually being extruded in a slow process that can be called "anagen loss." As a rule it is not until the twelfth to the sixteenth postoperative week-and on occasion not until the twentieth week-that new hair growth begins, and it is not until 9 months after the second transplant session (which takes place 6 weeks to 4 months after the first) that some cosmetic improvement is realized. Four transplantation sessions are typically required; on the most compressed schedule possible the fourth session is achieved no earlier than 9 Yz months after the first. Significant improvement (regrowth of the frontal hairline) cannot be attained in most patients until 2 full years after the last of these four standard transplant sessions. Clearly any method that shortens this "awkward period" would be welcome. METHODS Twelve healthy male volunteers, aged 21 to 60 years, who were undergoing the first hair transplant procedure participated in this open, noncontrolled pilot study. Each subject was given a complete physical examination, during which a detailed medical history and all
vital signs were recorded. Informed consent was obtained from all subjects, who were instructed not to use any topical medication other than the test drug during the study. Beginning 48 to 72 hours after surgery, each subject applied minoxidil 3% solution twice daily to the transplant area. Application was not begun earlier because of the high alcohol content of the medication and the possibility of increased systemic absorption through a fresh wound. Patients returned for postoperative observation 1 day after surgery and again I week later. When shedding occurred, and again when hair growth began, the patient made repeat visits to confirm these phenomena with the surgeon.
Transplant procedure Grafts measuring 4 mm in diameter were chosen for their hair yield per surface area. The donor area was infiltrated with a solution of 1% lidocaine (Xylocaine) with epinephrine. Saline solution was administered through a 30-gauge needle to increase tissue turgor. An electrically powered transplant punch (Bell hand engine) was used to harvest the grafts. Approximately 30 to 45 minutes elapsed between the harvesting and cleaning of the grafts and their insertion into the recipient areas. During this period the grafts were placed in roomtemperature saline solution. In nine patients the 4 mm grafts were inserted into 3.5 mm holes and in one patient into 3.25 mm holes. In the two remaining patients each graft was divided into four quadrants and each quadrant was inserted into a 1 mm hole. This latter technique not only permits the transplanting of individual follicles but it also refines the hairline to produce a more natural appearance. Four of the 12 patients (aged 34 to 43 years) received transplants in the vertex area. The number of grafts ranged between 40 and 75 per patient. The other eight patients (aged 21 to 60 years) received transplants in the frontal area. The number of grafts in this group ranged between 40 and 60 per patient (Table I). RESULTS
Two patients from this small study group (Nos. 8 and 10) demonstrated regrowth without telogen shedding. Both patients received transplants to the vertex area-50 and 40 grafts into recipient holes of 3.5 mm and 3.25 mm, respectively. Two other patients (Nos. 2 and 11) both of whom had ten 4 mm grafts subdivided into forty 1 mm sections and transplanted into I mm recipient frontal sites commenced visible growth on the twenty-eighth
Volume 16 Number 3, Part 2 March 1987
Minoxidil as adjunct to hair transplant surgery
687
Table I. Characteristics of patients and transplants Patient No.
I
1 2
3 4 5 6
7 8 9 10 11
12
Age (yr)
34 24 29 24 41 29 43 42 21 40 23 60
Telogen effiuvium
Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Yes
I
Transplant location
I
No. of grafts
Vertex Frontal Frontal Frontal Frontal Frontal Vertex Vertex Frontal Vertex Frontal Frontal
and thirtieth days after the initial shedding period-far sooner than the typical 12 to 16 weeks. The remaining eight patients showed regrowth between the twelfth and sixteenth weeks. DISCUSSION
From this small noncontrolled study it is not possible to generalize about the effect of topical minoxidil solution on postoperative shedding and regrowth after hair transplantation. Neither can a statistical correlation be made regarding the effects of age, location of transplants, number of grafts, and graft size versus recipient hole size on the outcome. However, it is of considerable interest that only four of the 12 patients underwent procedures in the vertex area, and two of these (patients 8 and 10) had no postoperative telogen shedding phase. An extensive literature search, as well as personal communications with surgeons whose experience with hair transplantation spans 25 years, has yielded no report of immediate hair growth without the initial telogen effluvium after hair transplantation. It is also noteworthy that two additional patients commenced visible hair regrowth on the twentyeighth and thirtieth days after the initial shedding period-far sooner than the typical interval of 12 to 20 weeks. In conclusion, topical minoxidil may be an appropriate adjunct to hair transplant surgery. A larger, controlled study is needed to establish the reproducibility of these findings-namely that top-
60 40 60 60 55 50 75 50 40 40 40 50
I
Graft sbe/recipient hole size (mm)
4/3.5 111 4/3.5 4/3.5 4/3.5 4/3.5 4/3.5 4/3.5 4/3.5 4/3.25 111 4/3.5
ical minoxidil may eliminate posttransplant shedding and hasten the onset ofpostshedding regrowth in some cases. The role of factors such as patient age and the number, size, and location of transplanted grafts in predicting these effects also needs to be determined. REFERENCES 1. Orentreich N. Autografts in alopecias and other selected dermatologic conditions. Ann NY Acad Sci 1959;83:403. 2. Davis JS. Scalping accidents. Bull Johns Hopkins Hosp 1911 ;16:257. 3. Okuda S. The study of clinical experiments and hair transplantation. Jpn J Dennatol Urol 1939;Oct:537. Gennan Abstr: Klinische and experimentelle untersuchungen uber die transplantation von lebenden haaren. Jpn J Dennatol Urol 1939;46:135.
DISCUSSION
Question. Have you thought about pretreating the donor area or the recipient area with minoxidil or putting the grafts into minoxidil solution before transplantation? Answer. I did think about that. The reason I did not pretreat the donor area is that I did not want to risk making the surgical procedure more complicated by possibly inducing more bleeding. In the last few years there has been only one patient in whom I had to halt a surgical procedure at the beginning because of bleeding. He was taking a peripheral vasodilator. As far as putting the grafts into the minoxidil solution, that is a good idea. We might do one test procedure, but I would prefer to place the grafts into a solution that contains no alcohol or propylene glycol; another vehicle perhaps could be used.