Hair transplant for the cleft lip scar? Why not
Hair transplant for the cleft lip scar? Why not? It’s unusual, but I’m glad I got it.
I was born in 1951 with a cleft lip that affected the right side of my nose. I did not have a cleft palate, but I do have a groove in the roof of my mouth. The series of surgeries started at six weeks and the last one I had was at age seventeen. The routine was to visit the plastic surgeon at six-month intervals. Sometimes surgery was scheduled; sometimes the word was, “Come back in six months.” There were several years when I had surgery twice a year. We literally lost count somewhere around twenty. Some were with a local anesthetic on an out patient basis, but most involved general anesthetic and hospitalization for a few days. There were two surgeries for a deviated nasal septum (still a problem). I continued to see the surgeon through my college years and up until he retired in 1974.
Two days before my moustache transplant
Through the years better surgical techniques have been developed. When I was a child, one of the neighbors was a retiree with a corrected cleft. His uneven bulging appearance was what could be achieved in the early part of the twentieth century. In the mid sixties I read a Readers Digest article about the family experiences of girl with a cleft. She had only four surgeries and I had already had had more than a dozen. When I asked why the difference, I was told that every patient is different. Years later, I learned that a new technique was developed in the early 1950’s. I speculate that my treatment had started with the older procedures, and she had benefited from the innovation.
In late 1973 my doctor proposed doing a hair transplant, using a graft from behind my ear. This was postponed because my mother was dying of cancer. The next time I saw the surgeon he announced that he was retiring. In the mid seventies my company offered HMO benefits. I made non-specific inquiries before signing up. I then had a consultation with a plastic surgeon. The results were not encouraging. The recommendations were, “Try to grow a moustache and see how it looks.” This was not a particularly useful suggestion as I was a very late in developing facial hair; I would be in my 30’s before I needed to shave daily (joke about a Thursday shadow instead of 5 o’clock shadow). The transplant never happened.
In retrospect, it is good it didn’t. The techniques of the time were to transplant strips or plugs. I might not have liked the results. The current technique is to transplant individual follicles, which are virtually unnoticeable. It would have been several years before I had a “real” moustache and in the meantime it would look a bit like Hitler. I also realized that a moustache alone would accentuate that my nose was crooked. In 1985, as soon as judged it would look mature, I let my beard and moustache grow out. It has been that way ever since but there was always a gap under my nose.
For other reasons in 2008, I was researching what could be covered in flexible spending programs. I was referred to IRS publication 502. The text excludes cosmetic surgery and hair transplants except as “necessary to improve a deformity arising from or directly related to, a congenital abnormality…”. This got me thinking. I was also at a point that I could very easily financially afford it.
The next issues were how to determine if it was a good idea and just how much would it cost. At my next visit to my GP, I asked for a referral to a specialist for transplanting hair for treatment of cleft lip scars. In addition, I also made a number of phone calls to nearby Emory Hospital and Medical School. I asked my insurance company if they had anyone in network to do hair transplants. The answer was a flat no, and although sympathetic, they had no recommendations as such things were not covered. Everyone was supportive and seemed to think it should be feasible, but no one was able to give me the name of someone who specifically did this kind of work. An internet search led me to the Cleft Palate Foundation I sent my photo to Lisa Gist and she passed it on to her contacts who were also encouraging, but still no idea who does this sort of procedure.
My moustache the day after surgery
This is an unusual area for a medical practice; there are few patients and few practitioners. The surgeons who work with cleft lips usually have patients that are too young to have a moustache; the facial surgeons generally do not do hair transplants and most hair transplant surgeons deal almost exclusively with scalp hair. Transplanting hair for cleft scars is a small market. Only a small fraction of men have a cleft lip scar and only some of them wear moustaches. Many at the age of having full facial hair have resigned themselves as to how their cleft scars appear. Never in my inquiries did anyone ask me, “Why would you want to do that?” No one said it was a bad idea. Several suggested that hair transplants near scars, with reduced blood flow, might have trouble surviving. I was encouraged but I still did not know of anyone who did this kind of work.
A further internet search as well as looking through the yellow pages led me to several hair transplant clinics in the Atlanta area. Phone inquiries were encouraging. I prepared my list of questions and made appointments. All of the surgeons had great credentials and instilled confidence. I guess everyone in the hair transplant field is experienced at dealing with fragile male egos when discussing cosmetic improvements. They were generous with their time, very open and gave forthright answers. They said more than one session may be required. The donor hairs would be selected for color and texture match. Scalp hair tends to survive better than body or beard hair. The follicles would be inserted at particular angles to give a natural appearance. One doctor with a chain of hair replacement clinics said that he had extensive training in facial surgery, including cleft lip repair, and extensive experience with scalp transplants. He did not particularly have a lot of experience with facial hair and none with hair near cleft scars. He would certainly consult with others in his chain of clinics. Ultimately, the one I chose had not only done transplants with scars but he also had experience with facial hair, including a complete moustache transplant for a patient.
I decided to go for it. Since my insurance would not cover it, I wanted to make sure beforehand that it was covered by my medical flexible spending program. At the end of the year there was considerable correspondence over whether or not it would be covered and the final ruling was that it would be. I then added the estimated costs to my paycheck deductions. I would still bear the expense, but it would be tax-free money.
In January, after flex spending arrangements were all set, I called for a surgical appointment. The earliest I could get an appointment was in mid February. The clinic requested a deposit to hold the date. They sent me pre-surgical instructions, post surgical instructions, and numerous forms for informed consent, up-to-date medical history, and payment arrangements. I was a bit taken back by the requirement for prepayment and the expenses for cancellation. This was my first experience with this type of surgery.
Then the doubts started. What if something goes wrong? How noticeable will it be when recovering from the transplant? Would I be satisfied? Since I design machines for the poultry industry, would I have to avoid going to a chicken plant to make sure the area does not get splashed? I had told only one brother and his wife and very few of my friends. Some of them said, “You look fine,” or “It doesn’t bother me.” Then things got somewhat complicated; I had to have rotator cuff surgery two weeks before the transplant.
All the doctors said that one surgery would not affect the other. On the first day back to work after missing four days for shoulder surgery, I told my boss I would be out again the two days the following week. Fortunately, this did not cause any problems.
Six months after the transplant
There were a number of preparations required. Control of bleeding is a significant concern. Some pain medications before hand can cause a problem. I kept a detailed drug dose log while recovering from the shoulder surgery. I shared this with the hair clinic. I was going to have two donor sites; scalp hair from the back of the head and hair from under the jaw. When they transplant beard or body hair, they want to use hair that is in a growing phase. If the donor area is shaved three days before the transplant they can tell which follicles to use. This led to another difficulty. Because I was unable to do a good job shaving left handed, I had to find a barber to shave me. Since there would be only local numbing I would not need to make arrangements to be driven home afterwards. The morning of the transplant I showered and used shampoo as usual, but no conditioner.
I showed up for my 10:30 appointment, signed more forms and the plans went forward. The donor sites were cleaned and numbed. Follicles were extracted and processed. After lunch my lip was prepped and numbed and the hairs were inserted. The initial injections were a bit painful, however, the pain control was quite good. By four o’clock I was on my way home with written instructions.
The lip area was pretty swollen for the next day and half. I had a series of small round scabs on my lip and at the donor sites. That night I absent-mindedly scratched my lip and one of transplants started to bleed. I cut a notch in a three-inch bandage pad to fit around my nose to wear to bed to make sure I wouldn’t do that again while asleep. I wore a bandage to bed every night for the first week. I also left it in place when showering so that spray would not directly hit the lip. After a few days the swelling went down and the small scabs got smaller and then disappeared. After a week it appeared that the hair was growing in the new place. It has great promise.
Today, I am satisfied with the results. I am glad I did it and I think I should have looked in to it several years ago. It is not realistic to expect that it will change my life, but I am pleased that I did it for me. I sent the surgeon a photo after six months and his response was that it was coming along fine. I will visit my doctor, Dr. John Cole, Alpharetta, Georgia, again at about the one-year anniversary for a further assessment. I would recommend this procedure for others.
Treatment trial for hair loss secondary to alopecia areata
This is an example of extreme alopecia areata. The affected area includes the eyebrows, front of the scalp, sides of the scalp, top of the scalp, the side burns, and part of the back of the scalp.
Alopecia areata is an autoimmune cause of hair loss. Often times it will result in isolated circles of hair loss. It often activates during periods of stress. The cause of this form of hair loss is poorly understood. It is often treated with topical or injected steroids.
We treated the area by injecting a combination of the patients own platelet rich plasma (PRP) and thrombin. The thrombin activates the PRP and the platelets release their growth factors. Prior to treating the area with PRP, we used a 1 mm microneedle in 4 different directions to stimulate the scalp. After injecting the combination of PRP and thrombin, we covered the area and left a coating of PRP on the surface of the scalp. The patient will remove the dressing in the morning and then wash the scalp.
Joe Greco has found that such treatments can be valuable in the treatment of severe forms of alopecia areata.
New Hair Transplant Treatments 2010
New Advancements in the Treatment of Hair Loss: PRP, ACell’s MatriStem & Micro-Needling
On January 22nd, 2010, Dr. John P. Cole and The Cole Hair transplant Group will begin offering several new treatments in conjunction with CIT (Cole Isolation Technique) hair transplant procedures. CIT hair transplant is Dr. Cole’s proprietary non-strip transplant technique in which follicular units are extracted individually with the use of specially-designed tools. The innovative treatments we will be offering include Platelet Rich Plasma, ACell’s MatriStem and micro-needling. Preliminary evidence shows that these treatments may have the potential to improve and accelerate post-op healing, increase hair growth, and reduce scarring. We encourage patients to take advantage of these exciting new treatment options.
Platelet Rich Plasma, or PRP, is a cell-based therapy that uses your body’s own natural cells to accelerate and significantly improve the healing process. Platelets are an important component in the clotting of blood. The theory behind PRP therapy is that, by increasing the number of platelets in a given site, growth factors will be released, promoting the process of tissue repair or regeneration. PRP is derived from each patient's own blood, which is separated to form a high concentration of platelets containing over thirty growth factors that promote faster healing, collagen synthesis, and the formation of new blood vessels. PRP is administered in the form of injections into the extraction sites to improve dermal healing. It is also offered as a topical gel for the treatment of donor areas. PRP could potentially help reduce the occurrence of hypopigmentation (“white spotting”) among some of our patients. We are also investigating evidence that PRP treatment may improve graft yield; one study found PRP improved graft growth by as much as 15%. We will continue to assess to what extent these possibilities prove to be accurate. PRP treatment is both safe and effective because it utilizes the body’s own natural cells to promote healing.
ACell’s MatriStem is an exciting regenerative medicine that uses extracellular matrix (ECM) devices to repair damaged tissues. MatriStem has even been shown to stimulate the regeneration of tissue with varying degrees of success. ECM lays the framework that cells use to generate a given body part, guiding the cells to divide or form themselves into a particular structure. ECM shows great promise in the field of regenerative medicine; scientists have already used ECM to re-grow fingers, and even organs. In the future, it is possible that ECM could be used to re-grow extracted hair, potentially providing patients with an unlimited donor supply. MatriStem, ACell’s ECM device, is currently offered at IHTI in a powder format, which is applied to patients’ donor regions to promote fast and effective healing.
Micro-needling is a form of collagen induction therapy that can be used to treat scars and improve the overall appearance of skin. Micro-needling utilizes a hand-held roller with hundreds of tiny surgical steel needles which stimulate collagen and elastin production in the dermis layer of skin. These proteins have been shown to directly improve the appearance of skin. Micro-needling is a less expensive and invasive form of skin rejuvenation and scar treatment than other options, such as laser treatment. We encourage patients to try micro-needling for the treatment of any scarring they may have in the donor region.
If you have any questions, or would like to request more information, about the treatments discussed in this article, please feel free to contact us at 1-800-368-4247, or at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
Autologous Platelet Rich Plasma (PRP)
Wednesday, 14 October 2009 14:48
How can PRP help you?
We are now offering PRP treatment to our patients. We will inject the recipient area prior to making incisions for the grafts. The recipient area will produce it's own thrombin and activate the platelets, thus stimulating them to release their concentrated growth factors. We are also offering PRP gel for the treatment of our donor area extraction sites. We will assess whether it improves healing and whether it improves the overall cosmesis of the donor area. We may find that it helps to reduce the occurrence of white spotting in some of our patients.Finally, we are offering PRP treatment to our patient's native hair before it falls out. Of course we cannot predict what the advantages will be for our patients, but we are hopeful that it will improve the coverage for our patients and prolong the life of their native hair. We anticipate that the growth factors will improve the diameter of growing hairs and thus improve the coverage. Of course it could also improve hair color, the total number of hairs in the growing phase, and the duration of the growing phase (anagen) for our patients. We will begin to study the benefits of PRP in patients who choose to treat their native hair with the PRP.
Patients, who refuse to take medications such as Propecia and Rogaine (Regain), may find that PRP serves as an adequate or better substitute to these medications alone. We will also be able to offer PRP to our female patients who thus far have had very little in the way of pharmacologic treatment for their hair loss.
In short, PRP offers many new treatment options for patients who are undergoing hair transplant surgery and for patients who wish to add a potentially significant additional treatment option to their hair loss.
What Are The Platelets?
Platelets were first described in the 1800s by the German anatomist Max Schultze. They are also called thrombocytes. They are formed by fragmentation of megakaryoctes in the bone marrow. They function in helping the body form blood clots or hemostasis. They also serve as a natural source of growth factors. Their life span is 8 to 12 days and the circulating life span is 7 to 10 days.
There are usually 150 to 400 X 109 platelets per litre. Around 1 x 10 to the 11th power platelets are produced each day. Each megakaryocyte produces between 5000 and 10,000 platelets.
Platelets contain dense granules containing ADP or ATP, Calcium, and serotonin and a-granules that contain growth factors, fibrinogen, fibronectin, B-thromboglobulin, vWF, and coagulation factors V and XIII. When platelets are activated they release the contents of these granules.
Platelets are activated by contact with collagen or by thrombin. They may also be activated by contact with glass.
Thrombin is derived from Prothrombin. The gene for prothrombin is located on chromosome 11. Factor Xa binds with Prothrombin to enzymatically form thrombin. The activity of Factor Xa is enhanced when Factor Va binds with Factor Xa, thus forming a prothrombinase complex. When Prothrombin acts with the prothrombinase complex, thrombin is formed by enzymatic cleavage of two sites on prothrombin.
Platelet rich plasma is a component of whole blood. There are several different cell types in the blood. One is the red blood cells, which caries oxygen to the tissue. The second is the white blood cells, which function as a deterrent to infection and has a role in the inflammatory process. The third is the platelet. The platelet functions as a hemostatic sealant, scaffold for tissue regeneration, growth factor concentration, and stem cell binding.
In whole blood, platelets exist in a lower concentration, but in PRP, they exist in a much higher concentration as seen in these two photographs. In their resting state platelets exist as tiny discs individually, but when activated, they spill their proteins, which are growth factors or cytokines. These cytokines increase linearly with platelet concentration. What this means is that as the concentration increases, the number of growth factors increases proportionally. Growth factors signal transduction via the receptor tyrosine kinases. Growth factors have many roles. The stimulate chemotaxis, which is directional movement in response to a chemical stimulaus. Stem cells are attracted to the growth factors and migrate into the area. Cell proliferation or cell division is a response to a stimulus by growth factors. Platelet signaling where growth factors bind to stem cell membrane and growth factor stimulates cell division.
The three primary benefits of PRP are stem cell binding, growth factor concentration, and tissue regeneration. Stem cells are stimulated to regenerate new tissue. The more growth factors released sequestered into the damaged cells, the more stem cells stimulated to produce new host tissue.
The growth factors in PRP include Epithelial Growth Factor, Fibroblast Growth Factor, Platelet Derived Growth Factor, Transforming Growth Factor - Beta, Transforming Growth Factor- Alpha, Interleukin 1, and Vascular Endotheial Growth Factor (VEGF).
There have been over 30 growth factors identified in platelets thus far. The benefits of many of these growth factors are summarized below.
Epithelial Growth Factor:
Stimulates re-epitheliazation, angiogenesis, collagenase activity.Fibroblast Growth Factor:
Stimulates angiogenesis, endothelial cell proliferation, collagen synthesis, and wound contracture. It also produces keratinocyte growth factor.Platelet Derived Growth Factor:
Activates TGF-beta, stimulates neutrophils and macrophages, stimulates chemotaxis, stimulates mitogenesis of fibroblasts and smooth muscle cells, stimulates collagen synthesis and collangenase activity, and stimulates angiogenesis. PDGF is produce by alpha granules in the platelets.Transforming Growth Factor- Beta:
Stimulates monocytes to secrete FGF, PDGF, Tumor Necrosis Factor-Alpha and interleukin-a, stimulates fibroblast chemotaxis and proliferation, potent stimulator of collagen synthesis, reduces dermal scararing, promotes cell mitosis, significantly increases type I collagen production in tendon sheath fibroblast, and reverses the inhibition of wound healing caused by glucocortiicoids. It is produce in alpha granules in the platelets.Transforming Growth Factor- Alpha:
Stimulates mesenchymal, epithelial, and endothelial cell growth, stimulates endothelial chemotaxis, and is a variant of Epithelial Growth Factor.Interleukin 1:
Stimulates lymphocyte proliferation and influences collagenase activity.Insulin Growth Factors:
Important in wound healing and stimulates both proliferation and differentiated function in osteoblasts.Vascular endotheial growth factor (VEGF):
Stimulates angiogenesis or new blood vessel development. This is important is re-establishing blood supply to the new graft and increasing blood supply to the grafted area, as well as repairing vessels damaged during the hair transplant process.As you can see, these growth factors are very important to the healing process. Concentrating the growth factors has been shown in numerous procedures to improve the outcome. Procedures that have thus far shown benefit include those Neurosurgery, Oral and Maxillofacial Surgery, Otorhinolayrngology- (head and neck surgery), Plastic Surgery, Urology, Periodontal Surgery, and Ortho/Spinal Surgery. Concentraion of the growth factors seems to play a large role in why there has been documented benefit from use of Platelet Rich Plasma (PRP). Just how much of an increase might you see? According to Eppley in 2004 Platlet Rich Plasma (PRP) increases growth factor concentration of PDGF, TGF-B, and VEGF are as follows:
1. PDGF 17 ng/ml (5 fold increase over whole blood)
2. VEGF 995 pg/ml (6 fold increase over whole blood)
3. TGF-B 42 ng/ml (3.6 fold increase over whole blood)
History
When discussing platelet rich plasma (PRP) it is worthwhile to consider the history. First, you must understand that it is derived from the patient's own blood, which means it is autologous so it is often referred to as Autologous Platelet Rich Plasma or (APRP). It was first developed in the early 1970s as a byproduct of multicomponent pheresis. The techniques and equipment for the production of platelet rich plasma (PRP) have significantly improved through the 1990s and beyond. Over the years, the benefits of platelet rich plasma (PRP) have been documented in many different surgical procedures as previously mentioned. It is only recently that platelet rich plasma (PRP) was introduced for hair transplant surgery.
Originally, it was used in storage mediums for grafts. More recently it has been used to inject all layers of the recipient with concentrated growth factors. Lee et al have found that the use of platelet rich plasma (PRP) speeds up the growth rate of grafts. They determined this by injecting one side with platelet rich plasma (PRP) and comparing it to the growth rate on the opposite side where no platelet rich plasma (PRP) was used. This study is still underway, however and more data needs to be collected prior to drawing any firm conclusions on the benefits of PRP to the rate of resumed growth of transplanted hair.
Even more recently, Greco has used PRP to inject the hair on the top of the scalp that is undergoing miniaturization due to androgenic alopecia. He has found that PRP improves coverage in up to 75% of patients who undergo treatment with PRP.
Photo Gallery
Why should you consider hair transplant surgery? Because you want to be your best. You want that self confidence that comes from looking your best. If you feel confident it will show in everything you do. It doesn't matter if its your personal relationships, your job, or every day situations. You will feel better. You will begin to accomplish the goals you set and succeed in every phase of life.
This patients exudes the confidence derived from hair restoration surgery.
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