Study on the Efficacy of Platelet-rich Fibrin Matrix in Hair Follicular Unit Transplantation in Androgenetic Alopecia Patients
Objective: Hair loss is a significant problem worldwide. The most common cause of hair loss in men is male androgenetic alopecia, male pattern baldness, which is primarily due to the presence of nonfunctional or dead hair follicles in the scalp. Hair follicular unit transplantation has been a widely used technique to transplant hair follicles into bald areas.
Although follicular unit transplantation generally gives satisfactory hair transplantation, efforts have been made to further increase the efficacy of follicular unit transplantation in hair regeneration. The crucial discovery of platelet-derived growth factors has resulted in the development of novel autologous therapeutic methods. Platelet-rich fibrin matrix represents a revolutionary step in the platelet gel therapeutic concept.
Technique For Hair Follicular Unit Transplantation in Androgenetic Alopecia
This technique is fast and involves minimal in vitromanipulations. In this paper, the authors studied the efficacy of platelet-rich fibrin matrix in conjunction with follicular unit transplantation for regeneration of new hair in bald areas in male androgenetic alopecia patients.
Design: Ten male subjects between 18 and 50 years of age with Norwood Alopecia from Grade 4 to 6 were chosen for the study.
Setting: The study was performed at Derma Solutions clinic, Bengaluru, Karnataka, India.
Participants: Patients with thyroid disorders, bleeding disorders, or other co-existing morbidities were excluded.
Results: The number of hair follicles began to increase progressively after platelet-rich fibrin matrix treatment was performed on the right side of the scalp and the effect was very distinct after six months of platelet-rich fibrin matrix treatment.
Conclusion: This study clearly indicates that platelet-rich fibrin matrix plays a key role in hair regeneration using follicular unit transplantation techniques. Further studies are needed to determine how platelet-rich fibrin matrix helps improve hair retention and regeneration. Additionally, it would be interesting to know how long the effect of platelet-rich fibrin matrix lasts after the termination of therapy. Thus, a future longitudinal study would be very useful. (J ClinAesthetDermatol. 2016;9(9):29-35.)
Hair loss is a significant problem worldwide and can be genetically inherited or caused by multiple factors, including a nutritional deficiency, autoimmune disorder, or an infectious etiology. The most common cause of hair loss in men is male androgenetic alopecia (MAA), male pattern baldness. MAA is the genetically determined loss of the normal thick hair follicle and is associated with progressive hair loss.
With MAA, a gradual conversion of terminal hairs into vellus hairs occurs in a highly reproducible pattern that leads to baldness. Studies on hair loss confirm that it is a genetically determined phenomenon.1 Hair transplantation techniques have been widely used to treat baldness. Extracting hair from the safe donor scalp area and implanting the hair follicles to an area with baldness is called hair transplantation. With the follicular unit extraction method, the punch graft technique is employed to extract follicles from one part of the head, which are then are transplanted into tiny holes or slits in bald areas of the scalp.2
Various strategies have been developed to assist hair transplantation in order to increase the efficacy of the method. The crucial discovery of platelet-derived growth factors (PDGF) in promoting wound healing, tissue regeneration, angiogenesis, chemotaxis, cell proliferation, differentiation, immune modulation, remodeling, and antimicrobial activity has resulted the development of novel autologous therapeutic methods.3,4 Importantly, a number of platelet concentrates can be prepared for therapeutic applications.
Various factors identified so far that are released by the platelets on activation are transforming growth factor alpha and beta (TGF-α and TGF-β), epidermal growth factor (EGF), fibroblast growth factor (FGF), keratinocyte growth factor (KGF), insulin growth factor (IGF), platelet-derived epidermal growth factor (PDEGF), interleukin-8 (IL-8), tumor necrosis factor alpha (TNF-a), connective tissue growth factor (CTGR), and granulocyte-macrophage colony stimulating factor (GM-CSF).5–7 These factors have a positive effect on tissue repair. The modes of action of these factors have been discussed elsewhere.8Platelets are easily collected from the bloodstream and are concentrated in a small volume of plasma known as platelet-rich plasma (PRP). Anticoagulants are typically used for this procedure.9 PRP is typically a two-step procedure.10–13 In the first step, the platelet concentrate is separated from the platelet-poor plasma (PPP) and white blood cell and red blood cell fraction. In the second step, the activator, such as calcium gluconate, is added to the platelet concentrate, which results in the formation of a fibrin network by converting the fibrinogen present in the platelet concentrate to fibrin. It is a short term and less effective procedure when compared to platelet-rich fibrin matrix (PRFM).
PRFM represents a new step in the platelet gel therapeutic concept with simplified processing without anticoagulants.14 Unlike other platelet concentrates, PRFM in contrast to PRP, isolates platelets and plasma after the first centrifugation itself. PRFM containing various growth factors has recently been used during follicular unit transplantation (FUT) to increase hair density and stimulate follicular unit growth. PRFM is the extraction of platelets from the patient’s own blood, which is injected back into the patient. Platelet-rich fibrin represents a revolutionary step in the platelet gel therapeutic concept.15 This technique, unlike the other platelet concentrates, involves only the centrifugation of natural blood without any additives. PRFM was developed by Choukroun et al16 in 2001 in France. The success of this technique depends on the speed of collection of the blood and transfer to the centrifuge as no anticoagulant is used.17A simplified processing technique without complex handling makes it superior to PRP.
In this paper, given the success and simplicity of the PRFM technique, the authors aim to ascertain the efficacy of PRFM in conjunction with hair follicular transplantation technique for the regeneration of new hair in patients in India, as not many studies have been done in India to date.
Materials And Methods
Study design. Inclusion criteria. Ten male subjects between 18 and 50 years of age with Norwood alopecia (type of classification of baldness, published in 1975, is the most widely used classification for hair loss in men. Hamilton-Norwood scale is usually employed to classify the progress of MAA, which ranges from grades 1 to 7) from grade 4 to 6 were chosen for the study. The study was performed at Derma Solutions, Marathahalli, Benguluru, Karnataka, India.
Exclusion criteria. Patients with thyroid disorders, bleeding disorders, or other coexisting morbidities were excluded.
Informed consent was obtained from all subjects and PRFM preparations were performed at DiponEd BioIntelligence LLP (Bangalore, Karantaka, India)
Ethics. The study was approved by Institutional Ethics Committee (IEC).
Preparation of PRFM. PRFM was prepared using DiponEd BioIntelligence LLP protocol that was approved by the ethics committee. About 10mL of blood was drawn from each patient in two sterile vacutainer tubes without anticoagulant and then the tubes were placed in a centrifuge at 3,000 revolutions per minute (rpm) for 10 minutes. After centrifugation, three layers were obtained; yellow-colored acellular plasma in the upper layer, red-colored red blood cells (RBCs) in the lower layer, and PDGF in the middle layer. The middle layer containing platelets trapped in fibrin meshes was used for applications in this study (Figure 1)
Treatment protocol. The male subjects were treated with intradermal injections of autologous PRFM three times; first at Day 0 prior to FUT, and subsequently in the second and third months. An equal number of follicular units was implanted in a 1x1cm2 area on both the left and right temporal area. Follicular density at a calibrated distance from the mid-pupillary point in a 1x1cm2 (right temporal area) area was measured using digital photographs taken at the one-, two-, and six-month follow-up visits. Hair density indices were compared using Trichoscope with photographs from similar areas (left temporal area) as control on same subjects without PRFM injections.
Statistics. Statistical analyses were made with the student’s t-test. A value of P<0.05 indicated statistical significance.
Results
Combined case studies on the efficacy of PRFM treatment on patients with androgenetic alopecia showed improvement in the hair follicle counts. In order to determine the efficacy of PRFM, the authors provided PRFM treatment for the subjects for a period of six months. Hair follicle counts were performed on 10 patients before and after implantation, with and without (control) PRFM treatment, and an equal number of follicular units were implanted in a 1x1cm2 area both on the left and right temporal areas throughout the entire study unless otherwise mentioned, whereas the PRFM treatment was only carried out in the same implanted 1x1cm2 area on the right temporal area. The post-implantation and PRFM treatment on the right side of the scalp were compared with the control (i.e., the left side of the scalp, not treated with PRFM post-implantation) at each indicated time period (Tables 2–4; Figures 2–4).
At the beginning of this study, the hair follicles were implanted in both the left and right side of the scalp and the numbers were compared between pre- and post-implantation as shown in Table 1. Post-implantation, only the right side of the scalp was treated with PRFM and the left side of the scalp was left untreated.
As shown in Table 2, the number of transplanted hair follicles had better retention of follicles post-implantation on the right side of the scalp treated with PRFM when compared to the left side of the scalp that was not treated with PRFM post-implantation. Thus, the PRFM treatment exhibited a beneficial role in retaining the hair follicle at the implanted area.
Next, the authors calculated the difference in the hair follicle numbers on both the right and left side of the scalp. Clear statistical difference and significance values were obtained after one month (25.60±3.38, P<0.001**), two months (21.50±5.09, 0.002**), and six months (26.00±4.63, P=0.005**). Numerical values are displayed in Table 3.
Having established that PRFM treatment showed beneficial effect on hair follicle numbers, the authors investigated the difference in the hair follicle numbers post-implantation and PRFM treatment both on the left and right side of the scalp. The results on the right side of the scalp (treated with PRFM) were compared to that of the left side of the scalp (control, not treated with PRFM). As shown in Table 4, at Day 0, hair follicle numbers on the right scalp (28.90±4.58) had reduced to (26.70±3.59) in one month and after six months the difference in the hair follicle numbers stayed about the same (26.50±4.93). In comparison, however, the hair follicle numbers on the left scalp went down as well; at Day 0 post-implantation, 28.90±4.58 reduced to 24.50±2.92 after one month, 28.90±4.58 reduced to 20.30±5.12 after two months. After six months of post-implantation without PRFM treatment, the difference became 25.50±4.53. The graphical representation of the data is presented in Figure 2.
Finally, the authors examined the effect of PRFM on hair retention after FUT. The effect was monitored from Day 0 to six months (Figure 3). As shown in Figure 3, the authors clearly observed improvement in hair retention after PRFM treatment post-implantation on the right side of the scalp as compared to the left side of the scalp (control) that was not treated with PRFM.
Discussion
Androgenetic alopecia (AA) is a genetically determined phenomenon that is defined by gradual loss and reduction of normal thick hair follicles. AA affects up to 30 percent of men over the age of 30 and 50 percent of men over the age of