According to the NHS, eight million women experience hair loss in the UK.1 For women in particular, the presence of strong, healthy hair is a societally recognised sign of beauty, youth, femininity and health; all of which are signs of sexual attractiveness.1,2,3
Here, we will discuss the use of direct injections of autologous products such as autologous adipose tissue (AAT) and autologous platelet-rich plasma (APRP) to stimulate and restore the hair for female patients. While the treatments discussed here bring us closer to allowing women to stabilise hair loss and improve the overall appearance, it should be clear that we are in the relatively early stages of the research and clinical use of these treatments, and we expect further advancements over the coming years.
Alternatives to surgery
As with male patients, there may be an organic or medical cause for the hair loss that can be identified through examination by a medical practitioner. These may include dermatological causes such as psoriasis4 or fungal infections,5 or a biological cause such as anaemia.6 Once such causes have been excluded, we can consider how to best help our patients. Unfortunately, many of the treatments available for men are unsuitable for women. For example, topical minoxidil can be difficult to apply in long hair and may give a greasy appearance, and oral finasteride or dutasteride is untested in women and may result in unexpected adverse effects.5 More evidence is required for the use of these drugs, and their side effects in female patients. For a small number of women, transplantation may be considered, however the nature of the hair loss in women usually means that locating suitable donor sites is challenging, and the resulting grafts may not be effective, resulting in false or artificial results similar to early attempts with male transplantation.
Combining AAT and APRP
In recent years, research into use of autologous products such as AAT and APRP has allowed us as clinicians to offer new ways to help women to restore thinning hair.
The concept is not new, and has in fact been used for many years in other branches of medicine regarding improvement of joint function, wound healing, treatment of sport injuries7 and increasing the speed of healing of skin damage.4,7,8 The scientific rational behind all tissue regeneration is the same, namely the settling of inflammation and the increase in interstitial communications, resulting in better direction of the regenerative systems to support, regenerate and restore the tissues to a healthier state.4 This is achieved by introducing the platelet growth factors and activated autologous regenerative cells into the environment, and works the same in hair as it does other parts of the body. Interesting work conducted and published by Gentile and Cervelli et al. indicates the promising use of combined AAF and APRP.4
In terms of hair restoration, its benefits can range from the use of simple equipment extracting growth factors from the patient’s own blood to inject into the scalp, up to the more highly advanced autologous fat processes requiring greater levels of skill and clinical experience to extract. These will require more advanced and complicated (therefore expensive) equipment, as well as specialist expertise, to offer such treatments.4
Our treatment method
Firstly, we aim to restore the growth potential of the hair follicular unit which has usually moved into a longer dormant phase in which the follicular body is still present, but produces only smaller and weaker hair shafts that shed more quickly. Secondly, we aim to improve blood flow and therefore oxygenation to the follicle, and thus allow the follicle to thrive and return to its previous growth capability. APRP and stromal vascular fraction (SVF) cells derived from adipose tissue increase the blood supply by enhancing the carrying capabilities of the vessels supplying to the follicular bodies.9 In the more advanced treatments, we can encourage the formation of new blood vessels in a process known as angiogenesis. By creating a stronger network of blood supply to the scalp, the follicle is encouraged to produce better, thicker and longer hair.9
The follicles that are arrested in prolonged catagen may also be stimulated into anagen, and so improve the density of hair covering the scalp with the appearance of new hair growth over six to 12 months.9 As part of the natural ageing process there is atrophy of the subcutaneous fat layer of the scalp. This results in the reduction of the regenerative cells, including stem cells that are found in this layer. By grafting autologous fat nano grafts to this area we can replenish the stock of regenerative cells, and so improve follicular and scalp health.8 The amount of blood required to produce the APRP will vary depending on the area treated. For APRP, we use the Angel treatment system, which we find is a good system because it produces predictable and measurable APRP.
Using this treatment system, we draw 60-120ml of venous blood from the patient. This will then be processed and separated using the Angel PRP device to provide a highly concentrated solution of APRP, as well as a volume of platelet-poor plasma (PPP) which can still be used as part of the procedure because it will also contain cells that will be helpful in the process, albeit not as effective.10 The main components of PPP are fibrinogen, fibronectin and thrombin. PPP is involved with haemostasis and coagulation, and acts as a cell attachment vector. It also promotes mitosis of fibroblasts and epithelial cells.8 PPP has been shown to sustain cell growth and survival.8 Our APRP device will typically produce 3ml of APRP and 20ml of PPP from a 60ml blood sample (i.e. APRP makes up 5% of the whole blood sample).
Most clinicians will have their first exposure to APRP through training courses that will demonstrate venipuncture and separation, usually with simple centrifuges. This is an inexpensive way of introducing providers to the concepts of autologous blood products for aesthetic use. The main problem we find with this is the quality and consistency of the final ‘product’ that can be extracted in this manner, as this will be manually aspirated from the test tube using syringe and needle in most cases. Extracting a high concentration of platelets in this manner is difficult to achieve, even in experienced hands, and will usually result in most of the product having low levels of platelet (as in the PPP mentioned previously) or indeed no platelets at all.6
In our protocol, when using APRP alone, we draw the product in 0.9ml ‘doses’ into 1ml syringes. To this we add 0.1ml of calcium gluconate to activate the product and increase its efficacy. The product is then deposited sub-dermally using approximately 0.05ml doses at a 2cm spacing into the scalp using 30-32 gauge mesotherapy needles. To complete the procedure, we use our PPP fraction in the same way, to either the same area or other areas that may be less affected. This has the potential for improvement through the wound repair mechanism following needle trauma and the formation of fibrin complex that is involved in the healing of wounds after tissue injury.
The procedure can cause considerable discomfort and our protocol is to apply topical anaesthesia (EMLA or similar) at least 30 minutes beforehand. We also recommend codeine pre- and post-treatment as long as the patient has no allergy issue. The use of ibuprofen or other non-steroidal anti-inflammatory drugs may also be of benefit and we have not found this to cause significant issues of post-treatment bruising or bleeding. In our hair protocol, this treatment is repeated at four weeks.
Managing expectations
In our experience, most patients will not see visible improvements for at least three months, with most starting to see results at four to six months. This will continue to improve over the subsequent 12 months and while treatment courses can be repeated at any interval, we generally recommend repeating treatment at between 12-18 months depending on the results. We will normally advise that with this form of treatment we should expect stabilisation of hair loss in 90% of treatment subjects, and more than 80% should expect visible improvement in the treatment areas. These are our own observations, which have been supported by a randomised double blind study.11
The younger the patient, the better the outcome of any regenerative treatment, especially when using cell enriched autologous fat grafting to follicular niche.5 With this in mind, we advise that these treatments have the best results in younger patients (35-45 years) as a standalone treatment, but can benefit older patients (over the age of 45) in combination with hair transplantation. This is because the quality of the scalp into which the hair follicular units are transplanted can be improved, which will support the transplanted follicles after surgery. Patients who are not suitable for APRP treatment include those with a platelet or other bleeding disorder, liver conditions and acute or chronic infections, or those that are taking platelet function inhibitors.12 Women who are pregnant or breast feeding should be excluded, as should patients who are being treated for auto-immune or malignant conditions, until their treatments have been completed.
Going forward
The use of autologous fat and APRP is gaining popularity as a modality in the treatment of androgenic alopecia in men, and we are starting to see its use extend to our female patients who have historically been underserved regarding this issue. We believe the market for hair restoration treatment using autologous products is still in its infancy, yet has potential for significant growth in the future. What are now needed are large-scale studies and standardised protocols for preparation of the autologous materials and their application.
