Efficacy of Autologous Nano Fat in Hair Transplantation By FUE In Cicatricial Alopecia.

INTRODUCTION

Cicatricial alopecia is a type of scarring alopecia caused by a wide variety of diseases that damage the hair follicle and replace it with scar tissue, resulting in permanent hair loss. ¹

Cicatricial alopecia (CA) is divided into two categories: primary and secondary. The permanent component of the hair follicle (stem cells of the bulge area and infundibulum) is the focus of a destructive inflammatory reaction in primary CA. ²

In CA, spontaneous hair regrowth is uncommon, disappointing the patient. There are numerous therapeutic trials planned to stop or reduce the disease's progression. ³

Hair transplantation is widely used nowadays as a cosmetic technique in the treatment of cicatricial alopecia by follicular unit extraction (FUE). ⁴

As a part of regenerative medicine, the role of adipose tissue in the hair growth cycle is promising nowadays. ⁵

Adipose-derived regenerative cells can differentiate into mesenchymal cells and secrete a number of growth factors that appear to have a role in neovascularization, which is significant in the treatment of cicatricial alopecia. ⁶

The goal of this research was to assess the efficacy of autologous nano fat in hair transplantation by FUE in cicatricial alopecia.

PATIENTS AND METHODS

This study was a Randomized clinical trial for 20 patients presenting with Scarring alopecia. The cases were recruited from Dermatology outpatient clinic of Al-Azhar University Hospitals from March 2021 to November 2021.

Inclusion criteria: Patients with cicatricial alopecia of scalp or beard area of the face post surgical, post traumatic or post burn of any size with maximum size is 25cm² were eligible and age: above 18 years old.

Exclusion criteria: Patient with body dysmorphic disorder and unrealistic expectations, patients with chronic severe illness, critical thrombocytopenia, patients on consistent use of anticoagulants within 48 hours of procedure and patient with local inflammatory skin disorders or infection at the site of the procedure.

Methods Taking a complete history age, sex, disease duration, family history, history of drug intake and history of other associated diseases and complete general and local examination.

The 20 patients were randomized into two groups: Group A: 10 patients presenting with cicatricial alopecia and were treated by autologous emulsified fat then hair transplantation by FUE after 1 month.  Group B:  10 patients presenting with cicatricial alopecia and were treated by hair transplantation by FUE only.

Procedures:

1)      Autologous fat

a)      Autologous fat harvesting

Donor site: The lower abdomen and thighs were identified as potential donor sites.

Tumescent anaesthesia: (500 ml of 0.9% saline solution, 1/2 ampoule of adrenaline 1 mg /ml, and 10-25 ml of lidocaine hydrochloride 2%, 10mEq/L NAHCO3) is infiltrated through a 2mm incision made with a number 11 blade in the donor area.

Using a 20-mL Luer Lock syringe and a 2.5mm-15cm harvesting cannula, we manually harvested 120 cc of mixed fat with tumescent solution from subcutaneous fat.

b)      Processing

The harvest syringe is placed vertically to decant for 3-5 minutes, allowing the layers to separate. The yellow adipose grafts quickly separate from the underlying infranatant fluid within the syringe based on their density, resulting in the grafts floating in the middle, with the lipid layer on top. We can expect a yield of 1.5 mL of fat graft for every 5 mL of aspirate, and we get about 40 cc of micro fat.

To reduce post-operative bruising, the donor area was covered with a sterile dressing with compression. The top layer of liquid is removed. The oil layer above the harvested graft should not be aspirated into the syringe for micro fat preparation because it can cause oil cysts. A single wash with Ringer's lactate solution should be sufficient to eliminate any remaining local anaesthetic solution and red blood cells

c)      . Emulsification Process

The cleaned microfat is loaded into 20 cc syringes and mechanically emulsified by shifting the contents back and forth 30 times between two 20 cc syringes connected by a 2.4mm connector, then 30 times with a 1.4mm connector, and finally 30 times with a 1.2mm connector, until the fat is liquefied and obtains a whitish appearance.

d)         Nanofat Process

 The emulsified fat is passed through the nano transfer block one time, which contains a double filter of 400mm and 600mm single use cartridge net and into a 20 cc syringe. This nanofat is transferred into 1 cc Luer Lock syringes for injection.

e)      Nanofat Injection

 Preparation of the skin with betadine then intradermal injection of nanofat (approximately 0.05-0.1 cc per injection point) The endpoint of the injection is reached with the appearance of a yellowish discoloration over the injection site (Figure 1). 

Fig 1: Autologous Fat injection instruments. A. Liposuction Cannula; B. Fat Connectors. C. Nano Fat Filter.

2)      Follicular unit extraction hair transplantation

 Follicular unit extraction hair transplantation  instruments based on micromotor,  handpiece, Jewelers  Forceps, punches of size 0.85mm & needle holder with slits or blade knife no.11.

a)    Preoperative Marking

Determine the hair line at a distance from the glabella, ranged from 7 to 9 cm from glabella.

b)    Donor site

Back & sides of the scalp. On the day of surgery the donor area from the back of the head is trimmed to 1-2mm length. The patient lies in prone position on the operating table.

c)      Donor site anesthesia

using a solution of xylocaine 30 ml with the addition of 30 ml of normal saline with adrenaline (1:1000) for donor and recipient block.The posterior occipital nerve is blocked by injecting the posterior hair line.

d)         Recipient site anesthesia

The supraorbital and supra-trochlear nerves are blocked by injecting 3 cm on each side into the supraorbital notch. The zygomatico-temporal nerve is blocked by injecting the hairline in the temporal region.

e)       Harvesting of hair grafts

In this study, punches with a diameter of 0.85 mm were used to harvest follicular units. During the process, hair follicle transplants are stored in cold saline on gauze.

f)       Creation of recipient sites and implantation of hair grafts

reation of the recipient sites in the recipient area with blade width about 1.1 mm carried on the needle holder.  Insertion of the graft with using of implantation forceps. The graft density in the recipient sites should not exceed 15-20 graft/cm² due to poor blood supply. 

g)      Dressing

 According to site, the closed dressing was removed from 2-4 days postoperatively. The total average time of operation was ranged from 2-4 hours in the post-traumatic or post-burn scar.

h)      Postoperative care

All patients received antibiotics for 7 days, anti-oedematous drugs, and analgesics after autologous fat injection. after transplantation, a bandage was applied to the donor site. To avoid excessive muscular contraction, the patient was advised to avoid solid food for 5 days. At 24 hours post-operative, the donor region was shampooed and the transplanted area was cleaned with normal saline at this time. The patient was told to keep washing the transplanted area with saline for another three days. After the 3-day period, the patient was told to wash both regions until the crusts completely faded. To avoid any damage or secondary infection, shaving was allowed after 15 days post-transplantation.

Fig 2: FUE Hair Transplantation Instruments. A. Micromotor & Hand Piece. B. Forceps for extraction and implantation. C. Punch. D. Needle Holder. E) slits

Administrative design Approvals: Verbal consent from the participants' parents was obtained.

An official written approval was acquired from the dean of the faculty of medicine, the hospital manager at Al Azhar University, and the head of the university's dermatology and venereology departments. Ethical committee approval was also required.

RESULTS

Table 1: Comparison between the studied groups as regard History. This table shows that there was no statistically significant difference between the studied groups as regard Diclofenac History.

Table 2: Comparison between the studied groups as regard No. of hair grafts. This table shows that there was no statistically significant difference between the studied groups as regard number of hair grafts.

Table 3: Comparison between the studied groups as regard Global photography. This table shows that there was no statistically significant difference between the studied groups as regard global photography.

Table 4: Comparison between the studied groups as regard outcome. This table shows that there was statistically significant difference between the studied groups as regard Improvement.