Hair Restoration Flashcards
A 45-year-old man comes to the office for consultation regarding hair loss concerns. He reports that he has a friend who underwent a hair transplantation procedure that looks unnatural, especially at the front hairline. Using the minigraft and micrograft strategy, how many follicles should be in a minigraft?
A) 1 to 2
B) 3 to 4
C) 5 to 6
D) 7 to 8
E) 9 to 10
The correct response is Option B.
Minigrafts consist of 3 to 4 follicular units and are commonly used in concert with micrografts which contain 1 to 2 follicular units. Larger numbers of follicular units have been associated with artificial appearing outcomes (plug look).
2017
A 55-year-old woman presents with androgenic alopecia. Her husband had a hair transplant 5 years ago. Which of the following characteristics of androgenic alopecia is more common in women than men?
A) More rapidly progressive
B) Not induced by dihydrotestosterone
C) Thinning tends to be frontoparietal
D) Topical minoxidil is ineffective
The correct response is Option C.
Unlike in men, androgenic alopecia in women tends to spare the frontal hairline and tends to affect the frontoparietal scalp. Like in men, it is a chronically progressive disease and causes miniaturization of scalp follicles through exposure of endogenous dihydrotestosterone in patients with increased scalp androgen receptors and 5-reductase concentrations. Topical minoxidil has been shown to increase scalp blood supply and slow hair loss in both males and females.
2017
A 34-year-old man comes to the office for a routine follow-up examination 1 month after undergoing extensive micrograft hair transplantation. He is extremely upset, complaining that “all the grafts have fallen out and are gone.” Which of the following is the most appropriate response to this patient’s concerns?
A) Loss of hair shaft is expected and part of the normal healing process
B) Loss of the grafts is a potential complication that was explained preoperatively
C) More grafts will be performed without additional surgical fees
D) The patient should wait and see what happens and return to the office in several months
E) The patient will be started on finasteride immediately
The correct response is Option A.
Hair shaft loss is to be expected after the first month following implantation as the hair follicles enter into the telogen phase. Initially, hair grafts enter the catagen phase of hair growth, which is a transitional phase. Implanted hair can grow 3 to 4 mm at this time. Following this stage, implanted hair grafts enter the telogen phase or the “resting” phase, which lasts for 3 to 4 months. During this phase, the attachment of the hair at the base of the follicle becomes weaker until the hair finally sheds, and the hair follicle is inactive and hair growth ceases. Almost every implanted hair falls out during this time, and patients must be prepared for this preoperatively. This phase can last up to 6 to 9 weeks, and this is when patients worry most about whether the surgery was indeed a success. Following this time, the anagen phase begins, generating new hair growth, which is initially quite thin. This hair then grows thicker with time. Final results of hair transplantation are not evident until 6 to 8 months in men and 10 to 12 months in women.
2017
A 27-year-old man comes to the office for hair restoration to correct alopecia of the scalp. He sustained a burn injury to the scalp when he was a child and underwent split-thickness skin grafting to treat the burn. Micrograft hair transplantion to restore the hairline is planned. Which of the following is the most likely percentage of micrograft survival and ultimate hair growth in this patient?
A) 10%
B) 25%
C) 50%
D) 85%
E) 95%
The correct response is Option D.
Because of their small size, micrografts and minigrafts appear to have a lower metabolic requirement to thrive. They tend to grow in areas of fibrosis and burn scars and over skin grafts and flaps, including split-thickness skin grafts. The rate of survival and ultimate hair growth under these circumstances appears to be approximately 85%, compared with approximately 95% on unscarred, healthy tissue. More recently, follicular unit grafts have been used in hair transplantation.
2014
A 13-year-old girl is brought to the office by her mother who is concerned about the child’s patchy hair loss. The mother began to notice the hair loss shortly after she separated from the patient’s father. The patient states she often plays with her hair throughout the day. Which of the following is the best course of treatment for this patient’s hair loss?
A) Administration of topical minoxidil 5% daily for six months
B) Injections of platelet-rich plasma to areas of baldness
C) Injections of triamcinolone to areas of baldness
D) Referral to a psychiatrist
E) Transplantation of follicular units
The correct response is Option D.
This patient most likely has trichotillomania, an impulse-control disorder. This is likely associated with a change in the patient’s social situation, namely the loss of involvement of her father in her life.
The other treatment options do have proven benefits in restoring hair loss, but the best course of treatment is first addressing the underlying cause, and referral to a psychiatrist would be the most appropriate step.
This patient has signs of telogen effluvium, alopecia caused by emotional stress. With appropriate psychiatric or psychological therapy, she should be expected to stop traumatizing her hair, and its growth would return.
The other options can improve thinning hair for various other causes, but they would not be the first course of treatment for this patient.
2020
A 25-year-old woman comes to the clinic to discuss eyebrow reconstruction. She reports that she tweezed her eyebrows several times a day because of perceived asymmetry, and she now has complete loss of eyebrows. She insists on receiving hair transplants and says that she is depressed because of her lack of eyebrows. Which of the following is the most likely DSM-5 diagnosis?
A) Body dysmorphic disorder
B) Borderline personality disorder
C) Excoriation (skin-picking) disorder
D) Major depressive disorder
E) Trichotillomania
The correct response is Option A.
Body dysmorphic disorder is considered an obsessive compulsive and related disorder in the DSM-5. Criteria include preoccupation with perceived appearance flaws for at least an hour a day, repetitive behaviors related to the preoccupation, clinically significant distress as a result of the preoccupation, and exclusion of an eating disorder.
The differential diagnosis includes major depressive disorder, trichotillomania, excoriation disorder, agoraphobia, eating disorders, and dysmorphic concerns. What differentiates body dysmorphic disorder from excoriation disorder and trichotillomania is the underlying preoccupation with symmetry and appearance seen in body dysmorphic disorder. In some cases, patients report a pleasurable sensation during hair pulling in trichotillomania. Thus, patients with body dysmorphic disorder can engage in skin picking and hair pulling, but the underlying motivation is different. Excoriation disorder is a body-focused repetitive behavior, on the obsessive compulsive spectrum, but it is not motivated by perceived asymmetry or appearance as is body dysmorphic disorder.
Depression can coexist with body dysmorphic disorder, but it does not have a preoccupation with appearance as a criterion.
Borderline personality disorder is a Cluster B personality disorder, characterized by unstable emotional responses to stimuli and relationships.
2020
An otherwise healthy 45-year-old man presents for evaluation of progressive frontal hair loss. He reports his grandfather went bald early in life. He is interested in surgical hair restoration methods but would prefer to avoid long, unsightly scars and prolonged recovery. Which of the following is the most appropriate method for hair restoration in this patient?
A) Follicular unit transplantation
B) Hair-bearing scalp flaps
C) Micrograft unit transplantation
D) Minigraft unit transplantation
E) Tissue expansion
The correct response is Option A.
This patient has androgenetic alopecia. Androgenetic alopecia, or patterned alopecia, is the most common form of hair loss in both men and women and is characterized by a progressive loss of hair diameter, length, and pigmentation. The genetic inheritance of androgenetic alopecia is well known, although the causative genes have yet to be elucidated. In genetically predisposed males and females, androgenetic alopecia is caused by progressive shortening of the anagen stage and an increase in the number of hair follicles in telogen. Follicular unit hair transplantation is the gold standard, because it preserves the natural architecture of the hair units and gives natural results. The follicular unit (FU) was first described by Headington in 1984 and was shown to include 1 to 4 terminal follicles, 1 or 2 vellus follicles, and perifollicular vascular and neural plexi, all surrounded by concentric layers of collagen fibers. Seager later showed that when single-hair micrografts were generated by breaking up larger FUs, their growth was less than when the FUs were kept intact, supporting the concept of the FU as a physiologic entity, rather than just an anatomic one. This gave rise to the FU transplant era, in which grafts are single FU or multi FU (2–3 FU). It was found that peripheral areas such as the hairline naturally have 1- and 2-hair FUs, whereas the more central regions have more 3- and 4-hair FUs.
“Micrografts” (1–2 hairs) and “minigrafts” (3–6 hairs) have been used in the past for hair transplantation but are not quite as effective as follicular unit transplantion and produce less natural appearing results.
Tissue expansion and scalp flaps are generally reserved for scalp burn wounds or wounds of traumatic nature with significant hair loss. They generally leave long scars and may require multiple stages and prolonged recovery which would likely not be acceptable for this patient.
2020
An otherwise healthy 26-year-old man with a receding hairline presents for hair restoration of the frontal scalp. Which of the following phenomena most accurately describes features associated with this patient’s condition?
A) Absence of vellus hairs
B) Decreased duration of telogen
C) Eosinophilic perifolliculitis
D) Increased duration of anagen
E) Miniaturization of hair follicles
The correct response is Option E.
Male androgenic alopecia is determined by a genetic predisposition. The normal anagen-catagen-telogen cycle is disturbed, and the anagen:telogen ratio is altered. This is due to the lengthening of the telogen denominator in this ratio. Additional aspects include gradual replacement of the normal hair shafts with vellus hair, miniaturization of the hair follicle, and an activated T-cell lymphohistiocytic perifollicular inflammation.
2021
Male pattern baldness is characterized by which of the following growth phase disturbances?
The correct response is Option A.
Male pattern baldness follows an X-linked dominant inheritance pattern. The anagen phase of hair growth is the active growth phase and lasts approximately 1000 days in men. In the anagen phase, follicular cells are actively multiplying and becoming keratinized. In men with normal hair growth, 85 to 90% of hairs are in this phase, with hair growing 1 cm per month. The catagen phase is known as the transitional or degradation phase and typically lasts 2 to 3 weeks and is characterized by atrophy of the bulb, with keratinization of the hair base, and separation of the hair base from the dermal papilla. The telogen phase of hair growth usually lasts 3 to 4 months and is also known as the resting phase and is characterized by the inactivation of the hair follicle, cessation of hair growth and hair shedding.
In men with normal hair growth, 10% of hair follicles are in the telogen phase, causing approximately 50 to 100 hairs to be shed on average per day. In male pattern baldness there is an increased percentage of hairs in the telogen phase and a decreased percentage of hairs in the anagen phase.
2021
Which of the following is a CONTRAINDICATION to the use of finasteride as a treatment for premenopausal women with hair loss?
A) Amenorrhea
B) Galactorrhea
C) Hirsutism
D) Masculinization of facial features
E) Pregnancy
The correct response is Option E.
Although FDA-approved for male-pattern hair loss, finasteride is not approved by the FDA for use in women. It is classified as Pregnancy Category X (highest risk) and should not be taken or handled by pregnant women, women who may become pregnant, or those who are breast-feeding. Finasteride has been linked to abnormalities of the external genitalia of a male fetus of a pregnant woman who receives finasteride.
The other choices are not common problems with finasteride, although breast tenderness has been reported.
European studies have selectively used the drug in women for cases of hair loss associated with hyperandrogenism.
2022
A 37-year-old man presents to the office for evaluation and treatment of an area of localized hair loss. Physical examination shows a 2 × 4-cm ovoid-shaped area of baldness on the temporal scalp. The rest of the scalp examination is normal. On the basis of the clinical findings, which of the following is the most appropriate treatment for hair restoration?
A) Hair transplantation
B) Rotational scalp flap
C) Serial excision
D) Topical ketoconazole
E) Triamcinolone injection
The correct response is Option E.
The most likely diagnosis in this clinical scenario is alopecia areata (AA). AA is different from other forms of alopecia since it is a T-cell–mediated autoimmune disease affecting the regional hair follicles. The exact cause is not fully understood, but it is estimated to affect about 2% of the population. Severity can be limited to a singular lesion or extend to multiple confluent lesions with severe impact on a patient’s mental health. While any given lesion can spontaneously resolve, the first-line treatment is injection of triamcinolone combined with minoxidil topical therapy. The injections usually have to be repeated. Systemic therapy with Janus kinase inhibitors is reserved for severe cases of AA. Clinical examination of a fungal infection with tinea capitis differs from the patient presentation in this case. Findings may include scaly skin, brittle hair, and broken hair shafts (black dots). Treatment includes oral and topical antifungal medication such as ketoconazole.
Hair transplantation is not a treatment for AA since the underlying pathology would also affect the transplanted hair follicles.
While a rotational scalp flap may be an option for a bald spot of this size, it would not be indicated in the setting of AA. The main reason is that hair can regrow spontaneously or in response to other therapy modalities. Further, the transferred flap can also become affected by AA in the future. A rotational flap would be indicated for closure of primary defects or other causes (e.g., burn scar, previous skin graft).
Serial excision is useful for a variety of pathologies such as scars, melanocytic nevi, or skin grafts. It would not be advised in the setting of AA.
2022
A 30-year-old woman is referred by her dermatologist for evaluation of scar alopecia after undergoing excision of a nevus over the right eyebrow. Examination shows absence of one-third of the right eyebrow hair. The patient undergoes single-follicle hair transplantation to reconstruct the eyebrow. Preoperative and postoperative photographs are shown. Four weeks later, the patient returns to the clinic because all of the transplanted hair has fallen out. Which of the following is the most likely cause of this patient’s hair loss?
A) Acute transplant rejection
B) Hair follicle shedding prior to regrowth
C) Inappropriate revascularization of scar tissue
D) Noncompliance with postoperative instructions
E) Postoperative cellulitis
The correct response is Option B.
Single-unit hair follicle transplantation is a successful method of eyebrow reconstruction. Eyebrow hair generally grows as a single follicle, and therefore hair transplantation with single follicle replaces like with like. Burned skin and radiated skin have decreased blood supply, and therefore revascularization of the hair follicle is challenging. In these cases, vascularized hair flaps may be preferred. In simple scars, the take for hair transplantation is reasonable. Once the hair is transplanted, the hair will enter the telogen phase (resting) and then the exogen phase (shedding) before entering the anagen phase (regrowth). The hairs will shed and then regrow in the next several months.
Infection to the face is rare from a clean and sterile surgery, since the face is very vascular. Loss of hair to infection is very rare. Repeat hair transplantation may be required to improve density, but generally there is take at each hair transplantation event. Many women also use a brow pencil to improve the appearance of density.
Postoperative care is important to avoid trauma to the fragile hairs or avoid pressure to the site so they do not evacuate from their implantation sites. Assigning blame to the patient may harm the physician-patient relationship. Rejection does not occur with autologous transplants.
2023
A 51-year-old man diagnosed with Norwood Stage 4 pattern of androgenic alopecia applies topical minoxidil daily. Which of the following best describes the proposed mechanism of action of this medication?
A) Alpha-granule activation leading to release of transforming growth factor and
vascular endothelial growth factor
B) 5-Alpha reductase type II inhibitor leading to decreased dihydrotestosterone
concentration
C) Cytochrome C oxidase oxidation leading to increased adenosine triphosphate
production
D) Potassium channel opening leading to blood vessel dilation
E) Prostaglandin F2alpha analog leading to increased outflow of aqueous fluid
The correct response is Option D.
There are currently only two FDA-approved drugs for the treatment of androgenic alopecia (AGA): minoxidil and finasteride. Several devices and modalities exist with promising data; however, the mechanism of action of many of these treatments is still not understood. Minoxidil is believed to work primarily by increasing blood flow by opening potassium channels leading to vasodilation at the follicular level, which promotes hair regrowth or hair stabilization in those follicles affected genetically by androgenic alopecia. Minoxidil was serendipitously noted to increase hair growth when the drug was studied as a potent treatment for hypertension because of its pronounced vasodilatory function. The drug causes hyperpolarization of cell membranes by functioning as a potassium channel opener. Blood vessel dilation (by opening potassium channels) allows more oxygen, blood, and nutrients to the follicles, theoretically causing follicles in the telogen phase to shed. These follicles are then replaced by thicker hairs in a new anagen phase.
Finasteride inhibits 5-alpha reductase type II, leading to decreased circulating levels of dihydrotestosterone, which leads to maintenance and/or increased amounts of terminal hairs in the anagen phase by inhibiting and sometimes reversing miniaturization of the hair follicle. Platelet-rich plasma is an emerging technology that shows significant promise in several medical disciplines. Through the centrifugation process, platelets are isolated from drawn blood and injected into the scalp dermis. Platelets are known to contain numerous growth factors (transforming growth factor-beta, fibroblast growth factor-2, platelet-derived growth factor, insulin-like growth factor-1, epidermal growth factor, hepatocyte growth factor, and vascular endothelial growth factor) in their alpha granules. Biologic activity occurs when growth factors come into contact with target receptors in numerous cell types. Bimatoprost is a prostaglandin F2alpha analog approved by the FDA (originally) for the treatment of ocular hypertension by increasing the outflow of aqueous fluid from the eye. Unexpectedly, increased eyelash hair growth occurred. The drug is being studied in larger cohorts to assess impact on AGA. Low-level light therapy (LLLT) has been shown to induce hypertrichosis in several wavelengths. The mechanism of action is thought to be mediated through the mitochondria cellular respiratory chain. Absorption of photons from LLLT leads to oxidation of cytochrome C oxidase, resulting in increased adenosine triphosphate production. Upregulation of growth factors due to this mechanism has led to cellular proliferation and hair growth.
2023
A 62-year-old woman comes to the office for a facial rejuvenation consultation. She also expresses dissatisfaction about the thinning of her hair over the last few years. Physical examination shows that she has maintained her frontal hairline and has generalized thinning of her hair. Which of the following is the most appropriate initial treatment for the female pattern hair loss in this patient?
A ) Bimatoprost
B) Finasteride
C) Minoxidil
D) Spironolactone
The correct response is Option C.
Female pattern hair loss differs from male pattern hair loss in that the loss of the terminal hairs in the affected region is usually incomplete. Thus, women will have diffuse thinning of the hair with preservation of the frontal hairline. There will be a visible reduction in hair density. The prevalence of female pattern hair loss is estimated at 19%.
Minoxidil is the first-line treatment for patients with female pattern hair loss. It has the strongest evidence for efficacy and is well-tolerated.
Bimatoprost is used for eyelash growth. It has been investigated for use in the scalp, but well designed studies are not available as of yet.
Dutasteride and finasteride are 5-alpha reductase inhibitors. Both are approved for use in male pattern baldness; however, use for female pattern hair loss would be off-label. Because of the anti-androgenic effects, 5-alpha reductase inhibitors are not recommended in women of childbearing age.
Spironolactone is an aldosterone antagonist that competitively blocks androgen receptors and weakly inhibits androgen synthesis. It is used as an adjunct to minoxidil. Its use in female pattern hair loss is off-label. Evidence supporting its use in hair loss is of a lower level.
Platelet-rich plasma has been touted to be of benefit in female pattern hair loss. However, once again, studies that suggest a benefit are limited in their design and are of lower levels of evidence.
2023
