Hair transplantation – stage of an articulated treatment process

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As you know, the transplantation is placed temporally within a complex process, which starts from the pharmacological treatment of androgenetic alopecia until the actual intervention.

Therefore, for optimal therapeutic success are absolutely essential two conditions:

    • The stabilization of the situation at the time of the intervention, which is achieved through the maintenance of native hair and the improvement of their state of miniaturization through drug therapy
    • The limitation of the traumatic effects of the intervention and the restoration in the shortest time possible of the health of the scalp, in order to maintain in the long term both the follicular units grafted in the recipient area and the indigenous hair, present at the time of the intervention

 

Requirements for a successful transplant

A generally accepted rule in trichology is that one should never wait one more day to start the pharmacological therapy; it is not inappropriate to keep repeating how important is the pharmacological care pre-transplantation for the perfect success of the same. This is because the improvement in hair quality in the donor area and the stabilization of calvaceousness in the recipient area, with a simultaneous improvement in the quality of indigenous hair in the same area, constitute an indispensable prerequisite for obtaining a satisfactory and stable result over time.

A transplant performed at the wrong time, too early or too late, can jeopardize the outcome of the transplant and, ultimately, the satisfaction of the patient.

 

The post-transplant care

An often underestimated phase of the transplantation process, which leads the patient to rediscover the joy and well-being of healthy, thick hair, is the postoperative course.

In order to ensure that the transplanted hair takes root properly and to minimize the risk of complications that could affect the results of the surgeon’s work, there are a number of simple but essential precautions to be taken in the period immediately following the transplantation.

As can easily be guessed, hygiene, in this delicate phase, is of primary importance.

The onset of inflammation or dermatitis, in fact, could compromise the success of the procedure and the entire process undertaken.

The natural fall of the scabs that form after the operation, both in the donor and in the recipient area, is also fundamental for an optimal post-operative course: the scabs must fall off naturally, in order to reduce the risk of the grafted follicular units falling off, which is much greater in the presence of scabs.

It is also advisable to ensure that the grafted hairs are supported in the rooting and regrowth phase, which typically lasts up to 8-12 months after transplantation.

 

Detoxification

Beginning on the 5th/6th day after transplantation, it is possible to begin deterring with shampoo. It can be done by gently massaging all areas, including the recipient area, in circular movements, without the risk of the grafted follicular units escaping, while facilitating the spontaneous detachment of the scabs.

Obviously, it is of paramount importance to choose a shampoo that offers a gentle cleansing, so as not to irritate the scalp and the newly grafted units. At the same time, it is vital to keep the skin clean, supple and free of excessive sebum secretions and dandruff flakes.

The ideal shampoo should exert a strong keratolytic and sebostatic function in order to keep the scalp and hair in the best possible condition of hygiene and cleanliness.

 

Cicatrization and removal of scabs

It is now well known that the absence of scabs is a prerequisite for the grafts to be considered safe from the risk of leakage.

A study published in Dermatological Surgery in February 2006, which found that:

“For the first 2 days, pulling a hair always resulted in graft loss. From the 6th day onwards, traction on a grafted hair no longer caused the follicular unit to fall out. Exerting traction on a scab adjacent to the hair in the first 5 days after transplantation always resulted in leakage and subsequent loss of the grafted follicular unit. By 9 days after surgery, the grafts were no longer at risk of being moved.”

The study under review reaches the following conclusions:

“The presence of scabs in the recipient area extends the time interval in which follicular units are at risk of coming out of place after surgery. If excessive scab formation after hair transplantation can be prevented, this may lead to a reduction in the time period in which patients are at risk of losing their follicular units and may also allow patients to return to their everyday lives more quickly.”

-Dermatol Surg. 2006 Feb;32(2):199-207.Graft anchoring in hair transplantation. Bernstein RM, Rassman WR-.

 

It is, therefore, fundamental to reduce as much as possible the period of permanence of the scabs, both in the donor and in the recipient area.

Generally, some products are used to reduce the formation of scabs and facilitate their accelerated spontaneous detachment:

    • Some recommend softening the scabs by applying a panthenol cream a few hours before washing.
    • Others prescribe the use of Vitamin E oil or Aloe Vera, but remember that the scabs should be gently massaged with the fingertips of the fingers, in circular motions, never torn or removed with the nails.

They also recommend the use of Aloe Vera oil.

Using these steps, the scabs, and the risk associated with their presence of causing the grafted follicular units to fall off, should diminish in 15-20 days.

 

Use of Ozonized Oils

In recent years, following the multiple evidences found in studies conducted on the ozone and its ability to modulate inflammation and regenerate tissues, as well as the ability to use as a substrate of reaction the double bonds of plasma lipids, it has come to the idea of reacting the ozone with vegetable oils.

Vegetable oils are in fact characterized by the presence of fatty acids (oleic acid, linoleic acid, linolenic acid, etc..) whose hydrocarbon chain consists of double bonds C = C (in unsaturated fatty acids).

The ozone, being a very reactive molecule, reacts with the double bonds available on the hydrocarbon chain, thus forming a stable structure, called “ozonide”.

In practical terms, this reaction takes place through the gasification of vegetable oil with an oxygen-ozone mixture.

Depending on the extent of oxidative stress damage that characterizes the specific lesion, products characterized by greater or lesser ozonation are developed.

They have shown that for highly inflamed tissues (e.g. ulcers, surgical wounds, etc.), therefore characterized by high oxidative stress, it is necessary to saturate the vegetable oil more;

Where on the contrary, the skin is intact and inflammation more moderate, the saturation should be lower.

Among the various vegetable oils, the one that best lends itself to the process of ozonation is the olive oil, as it has the highest content in oleic acid, and therefore a substrate rich in C=C bonds. The ozonized oil acts with several mechanisms of action, which can be summarized in a quadruple effect:.

A) Metabolic stimulation action of the cell.

  1. Activation of the pentose-phosphate shunt pathway with relative production of 2,3-diphosphoglycerate results in stimulation of oxygen release by hemoglobin and activation of glycolysis leading to production of ATP
  2. The direct action of ozonides that leads to a release of oxygen in ischemic tissues or in environments subject to degeneration

These actions can be summarized in a restoration of cellular metabolism, altered by the inflammatory processes to which the tissue subjected to surgical injuries is subjected.

 

B) Inflammation reduction action due to:

1) Inhibition of COX2 expression via suppression of the IkB-NFkB pathway.

  • This is equivalent to reducing prostaglandin production.
  • And therefore reduce edema and pain

2) Substrate supply for MAO and DAO (mono and diamino oxidase) activity

  • Reduction of serotonin and histamine production
  • Reduction of itching and redness

3) Reduction of mRNA levels of IL-1B, TNF-a, IFN-g, transglutaminase 2 and NOS2

4) Tissue regenerative action due to increased synthesis of growth factors:

Studies on animal models have highlighted how, following an injury, ozonated oil significantly accelerates the process of tissue regeneration. This is due to the increase in the synthesis of growth factors such as VEGF, PDGF, and to a lesser extent FGF and TGF

A study in humans found the same effects evaluated in the mouse model, and specifically:

  • Increased mRNA levels of VEGF (vascular endothelial growth factor)
  • Increased mRNA levels of HIF-1 (hypoxia-inducible factor)
  • Increased expression of E- cadherin: during tissue repair, cadherin-mediated cell-cell adhesion contributes to epithelial barrier reconstitution

3.The induction of moderate oxidative stress, resulting from the action of ozonides, acts as a second messenger in several cell signaling mechanisms.

Cells can, in this way, induce biological effects against oxidative stress to maintain biological homeostasis and adapt to stress.

In this case, the activation of the NRF2/ARE pathway induces the activation of a multiplicity of antioxidant enzymes and detoxification (superoxide dismutase (SOD), catalase (CAT), phase II enzymes, etc.).

Ultimately, the complex of the above activities leads to a significant reduction of apoptosis, the programmed cell death responsible for the morphological alteration and finally the functional loss of an organ, in our case the follicular unit.

 

Bactericidal and virustatic action of ozone (and consequently also ozonized oils)

Oxygen, internalized via ozonides, reacts with protons to form hydrogen peroxide, which has bacteriostatic and bactericidal activity.

For a cute, such as the scalp that has just undergone surgery (which alters the protective integrity of the skin, the first barrier to protect us from pathogens in the surrounding environment), applying a product with such properties can be an excellent solution. This is to avoid the occurrence of unlikely, but not excludable, infections.

Most hair transplant surgeries, whether they are performed using the STRIP or FUE method, involve shaving the scalp. This action is performed to allow the surgeon a better visibility and cleanliness of intervention. In this regard, an important support that is provided by ozonized oils is to have a photoexposure protective effect.

This activity could be of absolute importance for those who undergo surgery in the hottest months of the year. Particularly for those who want to expose themselves to the sun’s rays at the appropriate time, but who, by wearing headgear, want to avoid exerting friction that could lead to the removal of residual scabs (with loss of follicular units).

It goes without saying that, accelerating tissue regeneration from the basal to the apical layers (stimulating fibroblasts, keratinocytes, restoring epidermis and stratum corneum) will also accelerate post-transplant scab fallout. This will improve the percentage of rooting, and at the same time, the quality of the dermis in which the follicular units are immersed.

A dermis that more rapidly sees the inflammatory state triggered by the surgical procedure extinguished is equivalent to a future tissue that is less fibrotic, more vascularised and therefore more trophic. All this translates into an optimal substrate for the proper functioning of the follicular unit just transferred to the recipient area.

 

Regrowth stimulation

The enrichment of the grafted follicular units is certainly facilitated by the systemic intake of substances that introduce growth stimulation factors and that also exert an anti-inflammatory action, synergistic and complementary to that exerted by the ozonized oils.

It is undoubtedly advisable to take a good dietary supplement containing substances useful for hair regrowth, such as the MSM (methylsulfonylmethane), whose properties derive largely from its sulfur content in bioavailable form.

Sulfur is an essential component of living cells, and expresses its highest concentrations:

  • in muscle proteins, in particular in sulfur amino acids (cysteine, cystine, methionine, taurine, homocysteine)
  • in some coenzymes (e.g. glutathione, alpha lipoic acid, coenzyme A)
  • in certain hormones (e.g. insulin)
  • in some complex lipids (glycophospholipids of nervous tissue)
  • in certain vitamins (thiamine and biotin)
  • in some polysaccharides (it is present in glycosaminoglycans, such as the chondroitin sulfate of articular cartilage).

Disulfide bonds (S-S) are extremely important in protein structures, to which they confer toughness and rigidity, and in particular, in keratin.

Therefore the MSM stands out for some of its properties:

  • Anti-inflammatory properties: so important in the post-transplant phase
  • Increased trophism of skin and hair – for better rooting, faster hair regrowth and greater skin well-being
  • Promotes healing of wounds – especially those induced by surgery

A good supplement to take in the post-transplant phase would also contain Cysteine, an amino acid known for its cell turnover action, due to its ability to form disulfide bridges. Such bridges strengthen and stimulate the production of Keratin.

Keratin is among the most abundant proteins in skin and hair, and is richly composed of L-cysteine. This goes on to form disulfide bridges, strengthening keratin and giving it greater rigidity. For this reason, the use of L-cysteine-containing formulations have been shown to actively promote the repair of structural lesions and promote growth.

The cysteine also exerts a strong antioxidant action, since it acts as a precursor to the synthesis of glutathione, an important antioxidant. This is possible due to the ability of glutathione to neutralize reactive particles that can damage cells and tissues. For this reason, post-transplant supplementation with L-cysteine can restore glutathione synthesis where compromised, improving the balance of oxidoreduction and promoting a reduction in oxidative stress.

In addition, the reduction of free radicals brings consistent benefits in the healing time following surgical procedures, including, of course, the hair restoration.

A dietary integration protracted throughout the period of rooting and regrowth of the grafted hair (8/12 months) can certainly catalyze and consistently improve the result of the transplant.

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