Another look at aesthetic hair health. Therapeutic procedures.

Innovations in hair regeneration medicine.

David Poisbleau, MD
Department of Plastic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil

According to the communications from

Sophie MENKES, MD,

Byong SEUNG CHO, MD, CEO of ExoCoBio

Lofti BENSLAMA, MD

Platelet-rich plasma (PRP), follicular stem cells and adipocyte-derived stem cells : what impact does this have on hair regrowth?

Sophie MENKES, MD, Switzerland,  Pioneer in Aesthetic Gynecology & Internal Medicine.

Introduction.
Hair is a symbol of strength and power, and can be a tool of seduction.
At his consultation, S. MENKES regularly receives patients who have lost their hair after chemotherapy, often with a strong emotional reaction to the loss of their hair.
One of the tools to help hair regrowth is regenerative medicine, via regulation of the hair cycle by increasing vascularization and cellular and nerve regeneration.
Several genes of interest for the follicular cycle have been identified, in particular the MYB gene, coding for a follicle regulatory protein. It finely regulates the homeostasis of the skin and the hair capital. It has been shown that hyper-expression of this gene in skin cells induces hair loss in mice. Dr. Yuan Hu et al.
Why use adipocyte-derived stem cells?
Adipose tissue plays a major role in this cycle: a permanent exchange between the fat cells and the hair takes place, helping follicular growth during the anagen phase.
Conversely, the adipose tissue decreases during the catagen phase and accompanies the disappearance of the follicle.
This has been demonstrated in mice, with a slowing of follicular growth in individuals treated with an adipocyte growth inhibitor (transcription factor PPARg).
The adipose-derived stem cells (ADSC) represent 2 to 10% of the stromal vascular fraction (stroma vascular fractionSVF). They have a role of differentiation and secretion of signals and growth factors which will regulate tissue homeostasis (growth of the vascular wall, fight against cellular senescence, etc.).
All of this secretory product of the ADSC is found in the secretome, which is the set of secretory products transported from cell to cell by microvesicles.
The most famous of these transporters is the exosome. Their use via the nanofat in hair rejuvenation is of major interest.
The Nanofat technique
S MENKES performs the fat removal with the Hapifat® kit (1.65 to 2 mm cannula) and then rinse its contents with water (2 or 3 passes).
The Tulip® kit is then used with 30 passes for each connector (2.4 - 1.4 and 1.2 mm).
Finally, nanotransfer (400 micron sieve on one side and 600 micron on the other) is used to obtain the nanofat and destroy the viable adipocytes likely to bring volume.
The injection is performed 4 mm under the skin with a 27G needle, either by hand or with a Lipopen®.
The Rigenera® technique
This is a method of obtaining stem cells from the dermis, although in smaller quantities than from fat.
Cells are recovered with 3 biopsy punches (2.5 to 3 mm).
The grafts containing hair bulbs and the peribulbar space (fat and mesenchymal tissue) are then mechanically ground and filtered to obtain a mesenchymal cell-rich lyophilisate.
They are diluted in saline and then reinjected with a 33G needle into the scalp under local anesthesia.
Regen Lab's Platelet Rich Plasma (PRP) technique
Another alternative is PRP, which, after centrifugation of the plasma, makes it possible to recover a large quantity of autologous platelets, a natural source of cell growth factors.
As many studies have shown, it is also very effective for hair growth.
The injection technique is done in the same way as the nanofatby reinjecting approximately 4 mL into the scalp.
S. MENKES performs injections of 0.015 mL per point with a 33G needle, which are spaced 0.5 to 1 cm apart.
 
OBTAINING THE PRP
PRP CLASSIC
Comparison of the three techniques
A prospective multicenter study was conducted to compare the Nanofat, Rigenera® and PRP protocols by AIRMESS (Academy of International Regenerative Medicine and Surgery Societies).
120 patients were included and divided into 3 arms, following these 3 protocols.
The main objective was to quantify the evolution of the AGA score (androgenetic alopecia) at 9 months of treatment with 4 assessments during follow-up (at baseline and at 3, 6 and 9 months).
The evaluation was performed using the TrichoScan®. in order to obtain objective and quantifiable results via a non-invasive technique based on epiluminescence.
Several parameters were collected, such as the number of hairs per cm2of the capillary density, etc.
Intermediate results are interesting with thicker, shiny and abundant hair.
However, some data are missing to perform the final analyses and the study is not yet published.
We present some before and after results in the following illustrations (Nanofat technique).

Adipose stem cell exosomes for hair rejuvenation.

Byong SEUNG CHO,MD, CEO of ExoCoBio 

They are increasingly being studied in regenerative medicine and in the field of " cell-free therapy "Dr SEUNG CHO's team has developed a technique for isolating and purifying exosomes from adipose stem cell cultures (ExoSCRT® by ExoCoBio®).
Presented as non-immunogenic and without major side effects, these purified exosomes can be applied transdermally (via CD44 surface markers to penetrate the dermis) or intradermally, possibly combined with Botox or fillers.
Integrating numerous anti-inflammatory and regulatory organelles, they would be of interest in multiple indications: atopic dermatitis by reducing erythema and scars while reinforcing the skin barrier (the proposed protocol is 5 treatment sessions, spread over 2 weeks), facial rejuvenation, acne scars or even stimulation of hair growth
Exosomes are transport vesicles measuring 30 to 90 nanometers that are released by a cell into its environment. They contain many signals and cell growth factors, as do the ADSC secretion products discussed above. They allow intercellular communication via messenger RNA and play a role in cellular immunity.
They are increasingly being studied in regenerative medicine and in the field of " cell-free therapy "Dr. SEUNG CHO's team has developed a technique to isolate and purify exosomes from adipose stem cell cultures (ExoSCRT® by ExoCoBio®).
Presented as non-immunogenic and without major side effects, these purified exosomes can be applied transdermally (via CD44 surface markers to penetrate the dermis) or intradermally, possibly combined with Botox or fillers.
Integrating numerous anti-inflammatory and regulatory organelles, they would be of interest in multiple indications: atopic dermatitis by reducing erythema and scars while reinforcing the skin barrier (the proposed protocol is 5 treatment sessions, spread over 2 weeks), facial rejuvenation, acne scars or even stimulation of hair growth
 

How to optimize the hair transplant procedure.

Dr Lofti BENSLAM, MD, Maxillo-facial surgeon and stomatologist.

 The principles of hair transplantation: two main techniques,  the FUT (follicular unit transplantationand FUE (follicular unit extraction).

Follicular unit transplantation (FUT)

This technique involves transplanting hair from the crown region to the deplanted areas, via the removal of a strip of hair under local anaesthetic.
From this strip, grafts can be individualized with up to a single hair per grafted unit (called ultramicrografting).
These are then inserted into the depleted areas via suitable slots - with as little trauma as possible so as not to compromise the vascularization and quality of the surrounding tissue.
This limits fibrotic phenomena that are less conducive to the bedding of future grafts.
L. BENSLAMA recommends the use of small, atraumatic Kirchner wires for this purpose.
The actual insertion of the graft can be performed manually using ophthalmic forceps, or even robotically.
Morphological results were satisfactory, with correct capillary density at the graft site.
Normal density is 120 to 130 follicles per cm.2and it is difficult to exceed 80/cm2 with conventional techniques.
To optimize graft density, Dr BENSLAMA recommends a second densification session at a distance.

Follicular unit extraction (FUE)

This technique uses a different graft harvesting technique, with direct extraction from the donor zone in a single step using punches.
However, there is a risk of traumatizing the graft when the blade is inserted - and therefore of a lower yield, with up to 66% of graft loss (known as trans-section of follicular units).
This risk can be mitigated by the use of blunt/hybrid punches or larger punches, but with the consequent risk of a doll's hair appearance.
Finally, the graft is highly dependent on the quality of the adjacent skin grafted at the same time as the graft: the implantation technique must therefore preserve it as much as possible.

References

Hu, Yuan, Zhongya Song, Jiang Chen, and Carlos Caulin. "Overexpression of MYB in the Skin Induces Alopecia and Epidermal Hyperplasia". Journal of Investigative Dermatology 140, no 6 (June 2020): 1204-1213.e5. https://doi.org/10.1016/j.jid.2019.10.013.
Cho, Byong Seung, Jin Ock Kim, Dae Hyun Ha, and Yong Weon Yi. "Exosomes Derived from Human Adipose Tissue-Derived Mesenchymal Stem Cells Alleviate Atopic Dermatitis". Stem Cell Research & Therapy 9, no 1 (December 2018): 187. https://doi.org/10.1186/s13287-018-0939-5.
Ha, Dae Hyun, Hyun-keun Kim, Joon Lee, Hyuck Hoon Kwon, Gyeong-Hun Park, Steve Hoseong Yang, Jae Yoon Jung, et al. "Mesenchymal Stem/Stromal Cell-Derived Exosomes for Immunomodulatory Therapeutics and Skin Regeneration". Cells 9, no 5 (May 7, 2020): 1157. https://doi.org/10.3390/cells9051157.
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