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ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 3  |  Page : 1043-1049

Efficacy and evaluation of hair transplantation in patients with androgenic alopecia


1 Department of Dermatology and Venereology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Plastic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission09-Jan-2022
Date of Decision09-Feb-2022
Date of Acceptance20-Feb-2022
Date of Web Publication29-Oct-2022

Correspondence Address:
Marwa S ElKhesy
Shebin Elkom
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_15_22

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  Abstract 


Objectives
To evaluate the effect of follicular unit extraction (FUE) in patients with androgenic alopecia (AGA) and evaluate the satisfaction factors after surgery.
Background
AGA greatly influences individual's quality of life and psychological state. So, effective and available treatments are sought for patients with AGA. Among the different hair restoration methods, hair transplantation, especially FUE, is the most popular and acceptable option known for patients with hair loss.
Patients and methods
A prospective cohort study was conducted at the Departments of Dermatology and Plastic Surgery, Menoufia University Hospital, from June 2019 till October 2021. The study was approved by the ethical committee, Faculty of Medicine, Menoufia University. This study included 20 patients with AGA who underwent FUE and were followed up for 1 year. FACE-Q scale was used to assess the degree of satisfaction after FUE, and the factors that may affect patient satisfaction after surgery were investigated.
Results
This study shows that hair transplantation, especially FUE, has a significant positive effect on postoperative satisfaction with appearance among nearly 90% of participants. They appeared younger than their real age from their point of view.
Conclusion
Hair transplantation has evolved from follicular unit transplantation to FUE in patients with AGA, resulting in less surgical trauma and faster recovery. The FACE-Q scale is used to evaluate satisfaction in patients undergoing FUE. Larger studies included large sample sizes are needed to confirm our results.

Keywords: androgenic, alopecia, evaluation, hair, transplantation, scale


How to cite this article:
Gaber MA, Elsakka DM, ElKhesy MS. Efficacy and evaluation of hair transplantation in patients with androgenic alopecia. Menoufia Med J 2022;35:1043-9

How to cite this URL:
Gaber MA, Elsakka DM, ElKhesy MS. Efficacy and evaluation of hair transplantation in patients with androgenic alopecia. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:1043-9. Available from: http://www.mmj.eg.net/text.asp?2022/35/3/1043/359666




  Introduction Top


Androgenic alopecia (AGA) is characterized by progressive, diffuse, and symmetric hair loss[1]. The condition is due to genetically determined shortening of the anagen phase of hair growth[2]. Up to 70% of men and 40% of women will experience some degree of AGA in their lifetime[1].

AGA is known to greatly influence individual's quality of life and psychological state[3],[4]. Owing to these psychological effects, effective and available treatments are sought for patients with AGA[5]. Among the different hair restoration methods, hair transplantation is the most popular and acceptable option known for patients with hair loss[5],[6]. Contemporary hair transplant surgery offers results that are natural and undetectable, making it an excellent option of treatment for male and female pattern hair loss[7].

Hair transplantation has evolved from follicular unit transplantation (FUT) to follicular unit extraction (FUE), resulting in less surgical trauma and faster recovery[8],[9]. The surgery is performed in the outpatient setting using local anesthesia and takes 3–4 h for typical cases[10]. The procedure takes advantage of the predictable distribution of male pattern baldness[11]. The long-term success of transplantation is based upon the assumption that follicles in the posterior scalp are unlikely to contain the genetic determinants of androgenic atrophy and thus will survive in the frontal scalp where other follicles will not[12].

The key to a successful cosmetic dermatologic procedure is patient satisfaction, and high degree of patient satisfaction is essential for a successful cosmetic surgery[13]. Effective quantitative instruments for patient-reported outcomes are therefore needed to objectively demonstrate the effect and efficacy of cosmetic procedures[14].

FACE-Q is a comprehensive set of scales used to measure the outcomes of esthetic procedures. This scale was independently scored with preoperative demographic characteristics such as age, marital status, family history (AGA), educational status, income, Hamilton's alopecia classification, satisfaction with appearance, visual age, and expected visual age, and postoperative satisfaction factors such as satisfaction with appearance, visual age, satisfaction with decision, psychological well-being, and social function[14].

The aim of this study was to evaluate the effect of hair transplantation, especially FUE, in patients with AGA and evaluate the satisfaction factors in these patients after hair transplantation cosmetic surgery.


  Patients and methods Top


A prospective cohort study was conducted at the Departments of Dermatology, Venereology and Plastic Surgery, Menoufia University Hospital, from June 2019 till October 2021. The study was approved by the ethical committee of Faculty of Medicine, Menoufia University.

All enrolled participants provided an informed consent from volunteers for participation in the study. This study included 20 Egyptian patients with AGA. All patients underwent FUE surgery and were followed up for 1 year.

The evaluation after surgery was done by FACE-Q scale to assess the degree of satisfaction after hair transplantation and most importantly, investigate the factors that may affect patient satisfaction after surgery. We used a positive questionnaire language to set each item to relatively plain words, such as 'I feel very happy to look in the mirror every morning (psychological well-being).' Responses to the items were scored with 'disagree' being given a score of 1 and 'agree' scoring 4. The overall responses to items were then standardized to a Rasch transformed summary score of 0–100. A higher score indicated better patient satisfaction.

FUE was chosen for all hair transplant operations as it caused less surgical trauma and faster recovery than FUT.

The data were compared with review of literature studies, such as 'Evaluating the satisfaction of patients undergoing hair transplantation surgery using the FACE-Q scales' by Liu et al.[15], who found that hair transplantation especially FUE improves patient satisfaction with appearance and affects their daily activities and social function, and 'The relationship between self-esteem and hair transplantation satisfaction in male androgenetic alopecia patients' by Liu et al.[16], who found that hair transplantation significantly elevates self-esteem level and increases satisfaction with appearance of patients with AGA.

All patients were subjected to full history, including age, sex, and occupation, education level, family history, alopecia grade, and previous treatment attempts. All patients underwent full laboratory investigations and dermatological examination of the lesion to assess distribution and level of alopecia according to Norwood scale in males or Ludwig scale in females and physical characteristics of the hair, including the caliber, wave, and donor density.

We used a dermoscope for assessing hair density to calculate the donor area by many methods, such as calculating the reliable donor area using a coordinate system, dividing the donor area into component areas, and determining the number of follicular units or the number of hairs in the donor area[17],[18].

A hair transplant with the micro-FUE technique is a noninvasive surgical method that guarantees great precision and accuracy. Postsurgery pain is rather mild, and healing time is fast. In fact, the patient can resume his/her normal activities within about 10 days.

Before proceeding with the extraction, the hair needs to be shaved. The operation is performed under local anesthesia. After numbing the donor area, the individual follicular units are extracted from the scalp with the use of a micromotor. The micro-wounds created by the extraction are so small that they heal spontaneously within a few days, leaving practically no scars. The extracted follicular units are stored in a cool, sterile, physiologic saline solution until they are implanted in the recipient area. Local anesthesia is also applied in the receiving area. We implanted the prepared grafts in the opening of the channels at the hairline on which the patient previously agreed. The follicular units previously taken were inserted into the open channels, inside which the hair will take root and begin to grow thick and healthy again.

Inclusion criteria were patients with AGA with positive family history who had coarse hair and good donor area that affected their psychological status and effect on their life.

Statistical analysis

Data were analyzed using IBM SPSS advanced statistics (Statistical Package for Social Sciences), version 24 (SPSS Inc., Chicago, Illinois, USA). Qualitative data were described as number and percentage. χ2 (Fisher's exact) test was used to examine the relation between qualitative variables as appropriate. P value less than or equal to 0.05 was considered significant, and all tests were two tailed.


  Results Top


The study included 20 cases, where 55% of them were 31–40 years old, 65% were married, 90% of them were males, 35% of them had university level of education, 55% of them had high income, and 85% of them had a positive family history of AGA. Overall, 30% of the studied cases had alopecia level grade 5, 60% of the studied cases were nonsmokers, and 15% of the studied cases were diabetic, as shown in [Table 1].
Table 1: General characteristics of the studied cases

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Satisfaction with decision, psychological well-being, and social function all showed positive results, as shown in [Table 2].
Table 2: Psychosocial characteristics of studied cases after surgery

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Overall, 60% of the studied cases had less recovery of early symptoms (such as severe hair loss, scalp itching, and dandruff) and 40% of the studied cases had more recovery of early symptoms. Our study demonstrated that 45% never had an effect on their daily life after FUE, 40% of studied cases occasionally had a little effect on their daily life after FUE, whereas 15% of the studied cases frequently had an effect on their daily life after FUE.

The concordance between preoperative and postoperative results of satisfaction of appearance was highly significant (P < 0.001), which indicated that hair transplantation significantly improved patients' satisfaction with appearance, as shown in [Table 3].
Table 3: Comparison of patients' satisfaction before and after hair transplantation

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The postoperative satisfaction with appearance had no significant statistical association with age, marriage, sex, educational level, income, family history of alopecia, alopecia level, smoking, DM, and early life effect, as shown in [Table 4].
Table 4: Association between preoperative satisfaction with appearance and postoperative satisfaction with appearance with other factors after surgery

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There was a high relation between presence of complication and presence of smoking and DM. The relation between presence of complication and smoking has a highly significant difference (P < 0.001), and the relation between presence of complications and DM had a significant difference (P = 0.049), as shown in [Table 5] [Figure 1] and [Figure 2].
Figure 1: A 35-year-old male patient complained of androgenic alopecia grade 5 according to the Norwood–Hamilton classification.

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Figure 2: A 38-year-old female patient complained of androgenic alopecia grade 5 according to the Sinclair scale.

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Table 5: Relation between presence of complication and medical factors

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  Discussion Top


A total of 20 participants were included in our study who underwent follicular unite extraction and were evaluated by FACE-Q scale. Overall, 90% of them were males. This might reflect how much the condition affects males, as androgenic hormones (testosterone) play an important role in AGA. Moreover, most of them were married; this might reflect how much the condition affects their social appearance toward his/her partner, family member, and effect on their life.

Regarding education level, 35% of the studied patients had high school education and university education which might be related to awareness of disease and modalities of treatment. Overall, 55% of the studied cases had high income (>10.000 LE), which is in accordance with high cost of hair transplantation surgery.

In addition, 85% of the studied cases had a positive family history of AGA, which confirmed that one of AGA etiology is related to genetic factors. However, 25% of patients had alopecia level grades 3 and a similar percent of patients had grade 4. In addition, 30% of them were alopecia level grade 5, which indicated that high level of alopecia affected highly on patient's appearance, psychological well-being, and their social function.

Our study corresponded with Liu et al.[15], who demonstrated that AGA was found to occur more often in men than women. Regarding the range of the age, our study results were different from Liu et al.[15], who mentioned that majority of participants were between 21 and 30 years old, but our study results demonstrated that majority of participants were between 31 and 40 years old, which was consistent with Liu et al.[16].

Regarding the marital status, our study results were in contrast with Liu et al.[15], who mentioned that majority of participants were unmarried, but our study results were in agreement with Liu et al.[16]. Regarding education level, our study results were in concordance with Liu et al.[15] and Liu et al.[16], who reported that the highest percentage participants had university education level and the lowest percentage had below high education level.

Regarding income of the studied patients, our study was in contrast with Liu et al.[15], who demonstrate that majority of studied cases had a middle income, and was in agreement with Liu et al.[16], who demonstrate that majority of cases had high income.

Regarding family history of AGA of studied cases, our study was in contrast with Liu et al.[15], who demonstrate that majority of them had no family history, whereas our study result was in agreement with Liu et al.[16], who demonstrate that majority of them had a positive family history. Regarding alopecia level, our study result was in contrast with Liu et al.[15] and Liu et al.[16], who demonstrated that majority of studied cases were alopecia level grade 3.

Evaluation of the postoperative patient satisfaction

Psychological state also affects the outcome of hair transplantation. Three indicators (psychological well-being, social function, and satisfaction with decision) were chosen as an ancillary to evaluate patient satisfaction after hair transplantation. Regarding psychosocial characteristics of studied cases after surgery, 75% of the studied cases were satisfied with decision of hair transplantation, which was in agreement with Liu et al.[15].

Overall, 90% of the studied cases were psychologically well off after surgery, which was in concordance with Liu et al.[15], who demonstrated that nearly 70% of the studied cases were psychologically well off.

Our study demonstrated that 80% of studied cases achieved improvement in their social function after surgery, which was in agreement with Liu et al.[15], who demonstrated that nearly 82% of studied cases achieved improvement in their social function after surgery.

Recovery of early symptoms (such as severe hair loss, scalp itching, and dandruff) and early life effect (such as sleep, bath, study, work, and travel) are two important indicators of postoperative satisfaction. Patients with smaller early life effect and less recovery of early symptoms were found to have better recovery and higher postoperative satisfaction.

Recovery of early symptoms and early life effect checklist was made based on the patient recovery information 6 months after the operation, which was useful for identifying the proportion of patients experiencing postsurgical symptoms. Regarding recovery of early symptoms, 60% of the studied cases had less recovery of early symptoms, which was in contrast with Liu et al.[15], who mentioned that majority of participants had more recovery of early symptoms.

Regarding early life effect, our study was in contrast with Liu et al.[15], who demonstrated that majority of cases occasionally had a little effect on their daily life after hair grafting, but majority of our cases never had an effect on their daily life after hair grafting.

Our results ensure that hair transplantation especially FUE is the best modality and is effective in improving the psychological status and quality of life of patients with AGA.

Hair transplantation significantly improves patients' satisfaction with appearance

Based on the comparison of patients' satisfaction before and after hair transplantation, our study was in agreement with Liu et al.[15], who demonstrated that most cases were unsatisfied with their appearance before surgery. According to satisfaction with appearance after surgery, our study was in concordance with Liu et al.[15], who demonstrated that majority of cases were satisfied with their appearance after surgery, and only about 12% of participants were unsatisfied with their appearance after surgery.

Our study was in agreement with Liu et al.[15], who showed that the concordance between preoperative and postoperative results of satisfaction of appearance was highly significant (P < 0.001), which indicated that hair transplantation significantly improves patients' satisfaction with appearance.

From the patients' point of view, visual age was significantly decreased 6 months after hair transplantation. They appeared younger after surgery compared with the appearance before surgery; the P value was highly significant (P < 0.001), which was in concordance with Liu et al.[15]. Therefore, hair transplantation is an effective way to increase patients' satisfaction with appearance.

Preoperative and postoperative factors affect satisfaction with appearance after surgery

An association was done between preoperative satisfaction with appearance and other factors before surgery. Data were analyzed using the level of patient satisfaction. The results of our study were in agreement with Liu et al.[15] and Liu et al.[16], who mentioned that there was no significant difference with respect to age, marital status, sex, educational level, income, family history of AGA, and Hamilton's alopecia classification/grade. Moreover, our results showed no significant difference between preoperative satisfaction of appearance and smoking and diabetes mellitus (DM).

An association was done between postoperative satisfaction with appearance and other factors after surgery. Our study was in concordance with Liu et al.[16], who mentioned that there is no significant association with age, marital status, educational level, income, family history of AGA, and Hamilton's alopecia classification.

Our study was in contrast with Liu et al.[15], who mentioned that there was a significant association with education level, income, alopecia grade, and the effect on early postoperative life. Our study mentioned that the association between postoperative satisfaction of appearance and educational level, income, alopecia grade, and effect on early life postoperative had no significant difference, which might be owing to small size of sample in our study.

Association between medical history of studied cases and presence of complications

Our study demonstrated factors affecting satisfaction of appearance before and after surgery, and also demonstrated factors affecting presence of complication related to medical history. According to factors affecting presence of complication, all diabetic cases had postoperative complication, indicated a significant value of presence of complication related to diabetes (P = 0.049). Moreover, all smoker cases had complications ranging from mild to moderate, indicating that a high significant value of smoking on presence of complications (P < 0.001). In agreement with Liu et al.[15], our study showed no significant value of presence of complications on postoperative satisfaction of appearance.


  Conclusion Top


Hair transplantation in patients with AGA has evolved from FUT to FUE, resulting in less surgical trauma and faster recovery, which has improved postoperative satisfaction of appearance, psychological well-being, early life effect, and social function.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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