Type of surgery: Strip (FUT)
Dr. Nakatsui was recently at the 2018 International Society of Hair Restoration Surgery annual meeting in Los Angeles. He sat down with his mentor, Dr. Jerry Wong–one of the most well known hair transplant surgeons in the world. He developed the lateral slit technique and continues to make new innovations in the field of hair restoration surgery. Watch for updates as we introduce some of them soon.
FUE is a hair transplant technique that is gaining popularity. There are many different types of punches used in the FUE hair transplant procedure and Dr. Nakatsui will choose which one is best for you. In the video below, Dr. Nakatsui goes through some of the punches he has used over the years. As did virtually all physicians doing FUE in the early days, he first started using a manual punch with a sharp, smooth edge. This penetrated the skin well but had a high relatively transection rate. The next advance was the development of the dull punch. This was again a manual punch and had the advantage of decreasing the amount of transection as the dull edge was less likely to transect a hair. This did work but had its own disadvantages, such as requiring a large amount of force to penetrate the skin in some patients.
The next idea was to use a motorized device to power the sharp and dull FUE tips. This made things easier but with the added speed of rotation came a slightly increased risk of hair transection. Even a dull punch can cut through a hair when rotating fast enough!
Subsequent to this came the development of the dull hex punch, as well as the fluted or trumpet punch, as well as the serrated punch.
Watch this video as Dr. Nakatsui discusses the different punches he has used, as well as the ones he favors currently.
1. Finasteride really does work
Finasteride (Propecia) is a medication that has been used for years for the management of male pattern hair loss. It is a 5-alpha reductase inhibitor, which decreases levels of dihydrotestosterone (DHT). The pivotal studies showed significant benefit for men with respect to slowing down hair loss. In addition, a meta-analysis (an analysis of multiple studies on the same subject) by Gupta and Charrette showed that 5-alpha reductase inhibitors are significantly more effective than placebo in increasing hair counts.
2. It does have sexual side effects but it is not high risk
A very common question is about the sexual side effects of Propecia. Sexual side effects from finasteride have been well-described and include erectile dysfunction and decreased libido. However, the true risk of adverse sexual side effects remains controversial. Some meta-analyses show an increased risk and some show no increased risk. However, a recent 2018 report published by Lee et al analyzed randomized, double-blind, placebo-controlled trials (the best kind) and found 15 such trials. The data from these studies were analysed together in a meta-analysis. The relative risk was approximately 1.66. In layman’s terms, if 1 out of 100 untreated people were expected to develop sexual side effects, then 1.66 out of 100 treated people would be expected to develop these side effects. This is not a huge increase.
3. It only works as long as you take it
I frequently get asked “What happens if I stop taking Propecia?” (more…)
Platelet-rich plasma (otherwise known as PRP) continues to be investigated as a treatment option for various types of hair loss. It makes intuitive sense that growth factors found in PRP would be beneficial for hair growth but results from PRP studies with respect to hair loss continue to be highly variable and it is unclear why this is the case. One possible reason is that administration regimens differ from study to study. Another possible reason is that different systems concentrate platelets to different degrees.
PRP concentration study
One small study published in the Hair Transplant Forum International in 2018 by Rose et al looked at four different systems: the Selphyl ® system, the Eclipse PRP ® system, the Arthrex ACP ® Double Syringe system, as well as generic yellow top blood collection tubes.
What did the results show?
The investigators looked at platelet counts in whole blood and platelet counts after being processed by the PRP systems. On average, the Selphyl system concentrated platelets 1.16 times, the Eclipse system concentrated platelets 3.23 times, the Arthrex system concentrated platelets 6.34 times, and the generic blood collection tubes concentrated platelets 1.67 times. (more…)
This is a question that Dr. Nakatsui would love to find an answer to. When injection of platelet-rich plasma (PRP) first came out as a treatment several years ago, he was very interested and tried using
it to improve the quality of the skin but was not impressed with the results. As a result, he put this on hold until he could determine if it was truly effective or not. It sounds like a great idea but does it truly work? He is waiting to be convinced because if it works, he would gladly offer it to his patients in Edmonton again. There is evidence of effectiveness for wound and joint healing but does this extend to skin and hair?
Is there a good study on PRP?
In 2016, there was a double blind, multi-centre, placebo controlled study (the best kind of study) done that compared injection of PRP and placebo (saline) (Dermatol Surg 2016; 42:1243-1247). Investigators looked at hair counts and hair mass index along with patient-opinion survey responses. Examination of hair counts and hair mass index showed there was no significant difference between the treatment group and the placebo group 26 weeks after injection. Interestingly, however, when asked about the results of the treatment, 13% of the treatment group felt that they experienced improvements in hair loss and hair thickness, and 26.7% felt their hair felt coarser or heavier after the treatment. The hair was examined objectively by someone who had no idea which patients were injected with PRP or saline, so there was no potential for bias. In this study, about 1 out every 4 patients thought their hair improved when it actually did not.
Wouldn’t it be great if we had a test that simply and reliably told you whether or not you had a genetic cause for your hair loss? If we did, then you could walk into a doctor’s office or lab and find an answer in no time at all. This would also benefit doctors as we wouldn’t have to rely on using our eyes and ears to get a good history and physical. There is a test that came out about 10 years ago to do just this called HairDX. It involved a simple swab taken from your cheek and its claim was that it could reliably tell if a patient was suffering from androgenetic hair loss and thus tell the patient if he or she would benefit from hair loss medications like minoxidil and finasteride.
It is still used by some doctors today but unfortunately, this test is not as accurate as we first hoped. In fact, HairDX might only be about 70% accurate. That’s a large number of cases that are incorrectly classified.
Why does HairDX give the wrong answer?
Minoxidil (Rogaine ®) is a commonly used topical agent for male and female pattern hair loss. Clinical studies have proven that it is effective for some patients (unlike most other topicals, for which virtually all have no real proof). However, it is not effective for everyone and it would be great if we had a test that could determine if the effort involved in applying Rogaine ® twice daily was worth it. At present, the only way to determine if it works is to try it for at least 6-9 months.
The importance of sulfotransferase for minoxidil responsiveness
It seems that there is an enzyme that may be involved in the efficacy of Rogaine ® and several studies have analyzed this enzyme in responders and non-responders. The enzyme is called sulfotransferase and the activity of this enzyme in plucked hair follicles appears to predict the responsiveness of patients to Rogaine ®.
According to an analysis of current and ongoing minoxidil response testing, this assay is able to successfully rule out 95.9% of non-responders. Not 100% but pretty close. If this test becomes commercially available, it could save some people a lot of time and effort. (more…)
We will occasionally request blood tests in women suffering from hair loss if the diagnosis is unclear. One of the tests we do is a testosterone (T) level as elevated levels of testosterone can be associated with hair loss and we want to rule out this possibility. Many times, however, the test result will reveal that the level is actually low. The question that arises is whether or not anything should be done about this. Dr. Nakatsui usually requests that the patient discuss this with her family physician to see if testosterone supplementation is reasonable. Over the years, some of the patients who went on supplementation have reported to us that their hair loss actually improved!
Should a woman with low T go on supplementation?
Whether or not to go on supplementation depends on a number of factors. Firstly, does the patient have any other symptoms of low testosterone, such as insomnia, fatigue, depressed mood, hot flashes, and vaginal dryness? If so, perhaps a case could be made to go on supplementation.
The other issue is that of side effects as one of the possible side effects is increased facial hair. Is the patient willing to deal with this?
The last question is whether or not supplementation will actually improve the hair loss. (more…)
For many years, we have used finasteride (Propecia) for male pattern hair loss and for many men, it has worked very well. However, in those men who are non-responders, another option may be dutasteride, a cousin to finasteride. Whereas finasteride is approved by the FDA for hair loss, dutasteride is not but has been used off-label for several years.
Both of these medications are 5-alpha-reductase inhibitors, which help improve hair loss by preventing the formation of dihydrotestosterone (DHT). The difference between them is that finasteride (FIN) inhibits 5-alpha reductase type 2, whereas dutasteride (DUT) inhibits 5-alpha reductase type 2 and type 1.
Which is stronger?
DUT is more potent and decreases DHT to a greater extent than FIN (90% versus 70%). However, the flip side is that side effects are potentially greater so many patients are reluctant to go on this medication for this reason. (more…)