I wanted to summarize my thoughts on platelet rich fibrin matrix (PRFM), as it relates to integration into my hair transplant practice.
I’ve now been out of residency just over 20 years, I know what I’m good at and have stopped doing things that I struggle with or tend not to consistently work. Hair is roughly 60% of my practice in facial plastic surgery, and we get really quite good and quite consistent results by following a few principles.
First, I’m pretty blunt with people and don’t sugarcoat things. While nobody can make everyone happy, and medicine is not math where things always add up, by being honest from the initial consultation, our incidence of disappointment is low. Not zero, but pretty low.
Second, we avoid the 3 pitfalls of hair:
- Too low of a hairline
- Too little hair over too much bald head
- Minimizing scars as much as possible.
Third, I have a great staff with very little turnover. These guys and girls are excellent at dissection and gentle placement.
With follicular unit strip surgery (FUSS), a long strip is excised from the donor region of the head. Microscopic dissection allows careful and minimally traumatic isolation of grafts for rapid transplantation into the donor region. We have sufficient manpower to do 4500 grafts in 6 hours, and do one case a day so that everyone is fresh. Grafts are kept chilled in preservative fluid and while I used to place all of the hair, then half the hair, then part of the hair, now the placers do all of the placement into the slits I make. They are simply better, faster, and gentler than me.
However, the fine-haired patient presents a bit of a problem. We’re trying to get the goal of hairs to transplant, and transplant them as true follicular units not minigrafts and my cutters are great at getting the root complex without a lot of extra tissue so that we can dense pack. But with fine hair, the roots are fine and there is very little surrounding subcutaneous tissue. If I tell them to cut the grafts a bit “chunky” well it’s not really dense packing of FUs’ then. And if we really isolate the roots then there just isn’t a lot of safe cushion around the important stuff.
Now I grew up on a farm, and I’ve always enjoyed planting things. I only applied to college after threats from my father, I wanted to be a farmer. Having planted somewhere between 2500 and 3000 actual trees, the farmer, not scientist, in me says that if you have fertilizer for a day or 2 it’s probably better than nothing, but if you have delayed release fertilizer put in each hole before you plant a tree almost all of them grow better. I know this from personal experience planting in mostly Virginia clay. Being a relatively simple guy, I “think” this is what is happening in the scalp (or face, when we place it into wrinkles).
So what fertilizer is available for hair? Laser? Nope. I’ll leave that for others to argue about but it’s not an option at my office. Minoxidil? Maybe. It might help transplanted hair grow faster or weaker grafts to be saved, but at the same time it might give the patient scalp irritation in a freshly operated field. I tell our patients that if they’ve been happy with it before and have not had problems that it’s fine to restart it at 10 days. I personally can’t tell any difference in these patients versus the others who don’t use it but it may do something.
My personal feeling based on 4 years of wound research with fibrin glue in the late 80s (which is fairly similar to PRFM ) and recent phone discussion with my research colleagues from that time period who are still involved with said research is that both platelet rich plasma (PRP) and PRFM likely act as “fertilizer” when placed into a recipient field. PRP likely gets washed away fairly quickly, although I cannot prove that at this time. But platelets are only the first part of the clotting cascade that starts healing. It’s quickly augmented and replaced by a fibrinous clot that is around for the 2 weeks or so that healing occurs in, in normal injury to tissue.
My old research buddy, still a professor at a Virginia university and I are playing around with a couple of fairly straight forward experiments to look at this but the main problem is manpower. I have little interest in operating on rats again and looking at microscopic slides of tissue for hours. But, some resident will likely volunteer and we can proceed.
To summarize: I think but cannot prove, that a person would likely get some benefit from PRFM placed in the first 2 weeks after surgery. After that, I suspect that the die has been cast and weak grafts will have either died or always be weak. That is what we see in seedlings in the field.
So I tell people about PRFM at their initial visit, particularly if they have fine hair, and they need to tell me before we start. I think one or 2 guys has changed his mind on day 3 or 4 and I’ll inject then.
For the record, I do not think PRP or PRFM fixes male pattern baldness (MPB). Your scalp, my scalp, and almost all healthy people have plenty of platelets and fibrinogen circulating around their scalp all the time, and it doesn’t do a doggone thing to block DHT production or metabolism. It may help in selected cases for as yet unknown etiologies but I offer PRFM to augment surgery. Just as spreading miracle grow on my back yard hasn’t yet grown a crepe myrtle or rose but if I put it in the hole when I plant the specimen, they do grow better in that first year.
And just to add, my deal with plants is that I’ll fertilize on planting, and water for 3 months. Then they are on their own. In my yard I’m 42 for 43 trees living for 7 or more years. That is a decent track record for a house husband.
The attached video discusses this and shows how we make the PRFM. While anecdotal, I am certain its doing something for these fine-haired guys. I think every single one that I have treated with PRFM and who has come back at a 5 to 7 month check has looked significantly better than I’d expect.
The real questions are:
1. Is it saving hairs that otherwise would have not survived?
2. Is it making all the hair simply grow faster?
3. Should we use it on everyone? It is not free and since we get consistently good or really good results on folks, is it worth the extra cost?
The video showing my discussion and production on PRFM is:
Below are a list of my publications and awards from the late 80s on fibrin glue which is quite similar to PRFM used at our office.
Publications related to this topic:
Peer Reviewed Journals:
1. Lindsey WH, Masterson TM, Spontnitz WD, Wanebo HJ, Morgan RF.
Seroma prevention using fibrin glue during modified radical neck
dissection in a rat model. Am J Surg 156: 310-313, 1988.
2. Lindsey WH, Masterson TM, Wilhelm MC, Spotnitz WD,
Morgan RF. Prevention of seroma using topical fibrin glue in a
rat mastectomy model. Arch Surg 125: 305-307, 1990.
3. Lindsey WH, Becker DG, Hoare JR, Cantrell RW, Morgan RF.
Comparison of topical fibrin glue, fibrinogen, and thrombin in preventing seroma formation in a rat model. Laryngoscope 105:241-243, 1995.
Awards related to this topic:
Finalist (Top 10 in United States) – Excellence in Medical Student Research
First Annual Symposium for Scientific Advancement and Excellence
Chicago, Illinois 1989
Mead Johnson Overall Excellence in Research Award
National Student Research Forum
Galveston, Texas 1989
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