Dr. Marc Avram

Eyelash Enhancement

Download latisse.pdf

 

Traction Alopecia

Traction alopecia occurs due to excessive tension on hair follicles, which cause the hair follicles to break, and if sustained, tension permanent loss of hair.  Traction hair loss most often occurs over the frontal temporal scalp of women, although men that braid their hair, wear extensions, or wear a tight pony tail, can suffer from traction alopecia as well.  Common contributing factors include excessive heat applied to hair follicles, excessive chemicals, and tension through extensions and hair styling.

 

If caught early, traction alopecia is often reversible by reducing the amount of heat, chemical, or tension to the follicles.  In addition, anti-inflammatory injections into the skin over several months can often restore the growth of hair follicles.

 

For patients that have long term loss or who do not respond to any medical therapy, hair transplantation can be a highly effective treatment option.  Transplantation, by removing hair from the back of the patients scalp into the areas of thinning of the frontal temporal scalp, can help restore natural frame around the patient’s face.

 

A typical cosmetic goal of a patient is to be able to wear their hair back in a pony tail without being self-conscious of having a high or recessed hairline.  The typical patient needs two procedures in order to help recreate a natural hairline through transplantation. 

Hair Care

In our practice, on a daily basis, we see women with substantial hair loss due to inappropriate hair care over many years.  There are a variety of myths and opinions regarding appropriate hair care.  While there is no definitive data, in this blog I am suggesting certain culprits that are common offenders toward damaging and destroying hair follicles.

 

Excessive heat, i.e. hot combs, tension - either through extensions, braiding, or wearing the hair in a tight bun, and harsh chemicals such as relaxants and Japanese hair straightening can, over time, cause damage and permanent hair loss.  Our office recommends women who do lose hair to any of the conditions above to make their hair stylist aware of their hair loss and to work as a partner to help minimize future loss. As with many things in life, striking a balance of how we like to wear our hair and present ourselves to the world, and what is possible without damaging the hair, is something that varies from individual to individual.

 

Women that do suffer from hair loss due to chemicals or traction can often successfully be treated in earlier stages of hair loss with a series of intralesional kenalog injections and topical steroids.  A combination of medical therapy and appropriate hair care often results in stabilization of hair loss and, in many cases, re-growth of lost hair.  For patients that do not see re-growth of hair after twelve to eighteen months of treatment, hair transplantation offers a safe alternative to help restore lost hair.  

Diagnostic Workup for Women with Hair Loss

Hair loss in women can be emotionally and psychologically devastating.   The gradual relentless loss of hair can lead to “see through” hairlines which have (unlike men i.e. Andre Agassi, Michael Jordan) no social acceptability.   

The first step to diagnosing women with hair loss is to see a hair loss expert such as a dermatologist.  A hairloss history and physical exam is performed.  The differential diagnosis of hair loss includes - medical conditions such as underlying thyroid disorders or iron deficiency, poor diet, medications, disruption of the hair cycle due to unusual physical or emotional stress, primary inflammatory scalp diseases, or loss due to chronic abuse from products such as hot combs, relaxants, excessive tension from braids.  If all of the above are ruled out, then the diagnosis of female pattern hair loss is made.

After a complete examination and  history, if a diagnosis is still unclear, a scalp biopsy is the gold standard to establish a diagnosis.  All hair loss conditions can be treated. The choice of therapy, length of therapy and success varies depending on the diagnosis.  For example, female pattern hair loss can be successfully treated with either topical minoxidil and/or  hair transplantation. Minoxidil is successful in the majority of women that use it for at least 6-8 months . Hair transplantation is the movement of natural one to three hair follicular groupings from the posterior scalp into the thinning frontal scalp. Our office has fifteen years experience in utilizing natural follicular groupings for transplantation.  The cosmetic standard for the procedure is to create increased density in a consistently natural appearing manner.  Our office performs the procedure using local anesthesia as an outpatient.   

In summary, women with hair loss should be able to establish a reason for their hair loss by visiting their regular dermatologist for a full diagnostic workup. Between medical therapy and hair transplantation hair loss can be treated for the majority of women.

 

Below is the before and after photo of a hair transplantation patient:

 

 

 

Donor Region

The limiting step in hair transplantation is the amount of donor hair available.  This makes efficient utilization of donor hair essential.  Currently there are two methods employed:

 

1)      Elliptical donor harvesting.

2)      Follicular unit extraction.

 

Elliptical donor harvesting is used in 90 % of the procedures.  Elliptical donor harvesting follows the same principles as other skin surgeries such as removing a mole or skin cancer.  The hair bearing skin in the back of the scalp is numbed with local anesthesia.  The length and width of the donor ellipse is determined by the donor density and desired number of grafts. It is better to take a longer and narrower donor ellipse to minimize the scar. Once the ellipse is removed the surgical site is closed with either stitches or staples which remain in place seven to ten days.  Elliptical donor harvesting is safe and allows the removal of hundreds to thousands hair follicles minimal damage to the follicles.

 

Follicular unit extraction (FUE) is an alternative method for removing hair.  This technique is most often utilized for patients that like to wear their hair short in the back.  The overwhelming majority of patients we transplant do not shave their hair in the donor area and therefore having a minimal scar in the back is of no practical concern but, for those that do, follicular extraction is an excellent alternative for donor harvesting.  FUE removes individual follicular groupings using a 1 mm - 1.3 mm wide punch.  Hundreds of follicular groupings can be removed during each session.  The incisions are so small no stitches are needed and the wounds generally heal with no visible scar.  The chief disadvantage of follicular unit extraction is that one cannot harvest as many hair follicles in each session as with the donor ellipse.  In addition, there is a higher rate of damage to the hair follicles upon removal, which may  compromise the yield of the transplanted hair on the frontal scalp. 

Female Hair Transplantation:

The chief complaint of women with female pattern hair loss is the thin see-through frontal hairline. Hair loss in women is socially unacceptable. Hair loss in men is upsetting, but thin see through hair or shaved scalps are socially acceptable.  For example, Sean Connery was voted People’s “Sexiest Man Alive,” even with his lack of hair.  You won’t find women with thin, see through hairlines on People magazine’s cover, there are no “Sean Connery’s”.

 

A complete medical history and physical exam is vital for all women presenting with hair loss. There are a variety of causes of hair loss including: female pattern hair loss, shock loss or telogen effluvium, medication induced hair loss, hair loss from poor diet, underlying medical conditions, poor hair care, and primary skin diseases.

 

 

Minoxidil is the only FDA approved medication to stabilize and regrow hair for female pattern hair loss. The key to success understanding it must be used  for at least 8-12 months before it begins to work. The majority of women that use medication will benefit from it.

 

Hair transplantation offers a safe, highly effective treatment option to add density to a thinning see through frontal hairline. The cosmetic standard is for the procedure to add hair in a consistently natural manner. A hair transplant takes advantage of the hairs in the back of the scalp the are NOT affected by female pattern hair loss. Thousands of  hair follicles are removed under local anesthesia  from the back of the scalp and are carefully placed as 1-3  hair follicular groupings between thinning hair follicles in the frontal hailine and half of the scalp.  The transplant takes six to twelve months to fully grow in and, once grown, it should grow long term. 

 

Hair transplantation is a safe, consistently effective treatment option to restore a natural frame of hair around the face.

Key Concepts during a Hair Transplant Consultation:

The consult is an opportunity for a patient to ask any questions they may have regarding their hair loss, medical therapy, and hair transplantation.  It is also an opportunity for the physician to create an individual treatment plan for each patient.

 

The consult helps establish whether or not a patient is a candidate for hair transplantation, the risks/benefits of the procedure, side effects, and long term realistic expectations from the procedure.  During the consult, all patients should be made aware that contemporary transplantation is consistently natural in men and women.

 

Key concepts to consider are how the caliber of a patient’s hair follicle will affect the perceived density from the procedure.  Patients with fine, thin hair will grow fine transplanted hair and those with thick wavy hair will grow thick wavy transplanted hair.  In addition, the amount of donor density the patient has will affect the amount of transplanted hair that is available for each procedure.

 

The ongoing hair loss due to male and female pattern hair loss will affect the density from a procedure.  If a patient does not use finasteride and/or minoxidil to help maintain existing hair, then as hair loss continues, future procedures may be needed to help maintain existing density.

 

Patients should be aware , if they choose to shave their hair or closely crop their hair in the donor area, a thin visible scar will be evident.  For the vast majority of patients this never will be an issue but occasionally a  patient does communicate that they like to occasionally shave their hair and it is important that they understand this before undergoing a transplant.  For patients that do express a desire to wear their hair closely cropped in the back, an alternative harvesting method is follicular unit extraction. 

 

Follicular unit extraction is the removal of intact one to three hair follicular groupings from the posterior scalp using 1 mm punch biopsies.  The surgical incisions in using 1 mm punches are so small that there is generally no perceived scar in the donor area.  Currently the ellipse remains the standard harvesting method because a surgeon is able to harvest more hair with less transection of hair during each procedure.  Follicular unit extraction’s chief limitation is the limited amount of hair and, more importantly, the higher transection of hair through this method. The caliber of hair, rate of hair loss, available donor density, use or lack of use of medications will together all help creat realistic expectations for each patient.

 

All patients should be encouraged to contact the physician or the staff with any questions regarding the procedure before scheduling the procedure.

Corrective Hair Transplantation

An unfortunate legacy from hair transplantation from the 1960’s through the 1990’s was the “pluggy cornrow” effect of ten to twenty hair grafts.  For many patients who underwent this surgery, instead of achieving a restoration of a natural hairline, the transplant created a new cosmetic problem. Fortunately, over the past several years, techniques have been developed that can substantially improve and often eliminate the unnatural appearance of large pluggy grafts. 

 

Options include adding a large number of one to four hair follicular groupings between the large plugs.  This has the effects of softening the harsh appearance of the plugs while further increasing the density.  Other options include surgically removing unwanted plugs that were inappropriately placed too low in the hairline or in the back of the head as well.

 

Non-invasive options include laser hair removal.  Laser hair removal is highly effective in removing pigmented hair after 5-7  treatments.  The advantage of laser hair removal is that it is  non-invasive, out-patient procedure  that   does help soften the harsh appearance of large plugs by removing 50% to 75% of the hairs within the plugs .

 

In 2009 , our office published  a peer reviewed paper describing the  use  a non-ablative laser to help also improve the cobblestoning,  rough skin texture from large, “pluggy”  grafts.   

Non-ablative lasers are  used to treat unwanted acne scars on the face and our office has now successfully applied the laser to help improve the scalp texture from large plugs . 

 

In order to see which option, or combination of options, works best a consultation in our office is recommended.

 

 

 

Low level laser light therapy update

Over the past two years there has been a lot of public interest in the role of low-level light laser therapy (LLLT) in the treatment for male and female pattern hair loss.  Two years ago the FDA approved a laser light device in the treatment of male pattern hair loss.  The FDA approval was for a mechanical device, which has a different standard of FDA approval than a medication.  FDA approval for mechanical devices is more based on safety.  To date the two FDA approved medications are minoxidil and finasteride.  Low level light laser therapy seems to be safe. 

The long-term efficacy of it for male and female pattern hair loss is still to be determined.  There are a few published reports as to its efficacy but no long-term well designed studies, unlike finasteride and minoxidil.

 

In our office we conducted two pilot trials with two different low level light laser therapy devices  in 2008.  We found the devices to be safe.  We were unable to determine any difference in hair count through photographs but through video microscopes we were able to demonstrate some thickening of hair follicles in some patients.  Our office currently believes that finasteride and minoxidil are first line medical therapies for genetic hair loss.  Low level light laser therapy seems to be a safe and promising alternative.  What is required is longer termed, well-designed studies to determine its exact role in the future.