Comparison Between Platelet Rich Plasma and Nanofat as an Adjuvant Therapy in Hair Transplantation in Male Androgenic Alopecia
Phase: NA
Conditions: Androgenic Alopecia
Sponsor: Sohag University

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Sohag University
 
Faculty of Medicine
 
Department of plastic surgery
 
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Comparison between Platelet Rich plasma 
and Nanofat as an Adjuvant Therapy in 
Hair Transplantation in Male Androgenic 
Alopecia
 
Protocol for thesis Submitted for partial fulfillment of the Doctorate 
degree in plastic surgery
 
Presented by
 
Shenouda Gamil Faiez
 
Assistant lecturer in plastic surgery department, faculty of 
medicine Sohag University hospital.  
 
 
11\11\2025 
 
 

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Introduction: 
 Androgenic alopecia is a genetically predetermined disorder due to excessive 
response to androgens, impacting approximately 50% of males and females.(1) 
 This condition is characterized by progressive loss of terminal hair of the scalp, 
typically occurring following puberty, with a distinctive pattern in both males and 
females. In males, hair loss is most prominent in the vertex and frontotemporal 
regions, whereas females tend to retain their frontal hairline while experiencing 
diffuse apical hair thinning, causing a broader appearance of the anterior part of 
the hair (2-4). 
 Humans have 2 types of hair follicle >terminal and vellus. Terminal hair follicles 
are larger and extend deeper into the skin, reaching the subcutaneous fat. These 
follicles produce thicker hairs, typically greater than 0.06 mm in diameter. In 
contrast, vellus hair follicles are smaller, reach only into the reticular dermis, and 
produce short, fine hairs typically less than 0.03 mm in diameter.. At birth, 
terminal hairs appear on the scalp, eyebrows, and eyelashes, whereas vellus hairs 
cover most other areas. During puberty, vellus hairs in regions such as the axilla 
and genital area convert to terminal hairs. Pathologic transitions can also occur. 
Vellus-to-terminal conversion is observed in hirsutism in women, whereas 
terminal-to-vellus transformation, referred to as miniaturization, is characteristic 
of androgenetic alopecia (5). 
 The hair growth cycle consists of 4 phases—anagen, catagen, telogen, and 
exogen. 
o Anagen: Anagen is the active growing phase of the hair follicle, lasting 2 
to 6 years. Approximately 90% to 95% of scalp hairs are in the anagen 
phase at any given time. 
o Catagen: Catagen refers to the involutional phase of the hair follicle 
characterized by acute follicular regression. Catagen typically lasts 2 to 3 
weeks, and at any given time, less than 1% of scalp hairs are in catagen. 
o Telogen: Telogen refers to the resting phase of the hair follicle, lasting 2 to 
3 months, and a cessation of all activity marks this phase. Approximately 
5% to 10% of scalp hairs are in the telogen phase at any given time. 
o Exogen: Exogen is the daily shedding of hair follicles characterized by a 
loss of 25 to 100 telogen hairs, replaced by new anagen hairs. (6) 
 The pathogenesis of Androgenic alopecia involves two main components: 
 (a) Hair follicle miniaturization: progressive miniaturization of the terminal 
hair follicles and eventual conversion of terminal hair to vellus hair. 
  (b) Changes to the hair cycle: shortening of anagen and an increase in telogen 
duration. . (7) 

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 
Historically, androgenic alopecia was treated with techniques such as plug grafts, scalp 
reductions, and transposition flaps. Today, hair transplantation is the standard surgical 
approach, which involves harvesting follicular units from the patient's occipital scalp. (5) 
 
In 1931, Okuda was the first physician to describe in detail the technique of autologous 
hair transplantation. He explained how circular punches were used to excise grafts from 
the scalp, which were subsequently inserted into holes made with slightly smaller 
punches in areas affected by alopecia (8) 
 In the mid-1990s the follicular unit transplantation (FUT) procedure, also known 
as strip harvesting FUT, involves excising a strip from the mid-occipital scalp 
followed by its stereomicroscopic dissection into follicular units. This results in 
long thin scars, which may be camouflaged by the remaining occipital hair, except 
in patients with very short hair. (9) 
 
In the early 2000s, follicular unit extraction was developed, using 0.8-1.0 mm punches to 
directly remove individual follicular units from the donor hair. As a result, there are no 
sutures and no linear scars. Follicular unit extraction has now surpassed strip harvesting 
FUT to become the most commonly used donor harvesting technique.(9) 
 Ideal candidates for hair transplantation typically present with a clear, stable 
pattern of hair loss, characterized by at least 50% thinning or balding in 1 or more 
areas. The scalp must be healthy, with donor hair of good quality and quantity. 
Patients must have realistic expectations and be free of medical conditions that 
compromise surgical outcomes. The safe donor zone is located in the mid-
occipital region between the upper and lower occipital protuberances, typically 
containing 65 to 85 follicular units/cm² (10) 
 Intra‑operative injection of PRP is beneficial in giving faster density, reducing the 
catagen loss of transplanted hair, early recovery of the skin, the faster appearance 
of new anagen hair in FUE hair transplantation.(11) 
 This study compares the effects of PRP and Nano fat as adjuvants in Androgenic 
alopecia patients undergoing FUE hair transplantation. 
 Nanofat contain stem cells supposed to improve the results of FUE hair 
transplantation (12), but the question that we hope to answer at the end of our 
study which one we recommend as an adjuvant therapy PRP or Nano fat? 
 
 
 
 
 
 
 
 

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Aim of the work: 
 
 To compare the efficacy of PRP and Nanofat injection as adjuvant therapies 
with FUE hair transplantation in improving graft survival rate,  
 To measure hair density and thickness postoperatively using dermoscopy or 
trichoscopy. 
 To evaluate patient satisfaction and photographic assessment by blinded 
evaluators. 
 To assess any adverse effects or complications related to each modality 
 
Materials and methods: 
Place of the study: Plastic surgery department, Sohag university hospital, Egypt. 
Type of the study: Prospective randomized control clinical trial. 
Number of cases: 30 cases, 10 in each group, 
Group A: Control group (FUE hair transplantation alone) 
Group B: FUE hair transplantation + PRP.  
Group C: FUE hair transplantation + Nanofat   
Inclusion criteria : 
1. Male patients with stable androgenic alopecia more than 2 years.  
2. Age 20-50 years  
3. No recent medical hair loss treatments. 
 Exclusion criteria : 
1. Active scalp infections or scarring alopecia. 
2. Systemic diseases affecting wound healing. 
3. Platelet disorders or anticoagulant use. 
4. Smoking or heavy alcohol intake. 
Plan of study : 
 All patients were subjected to full history taking, clinical examination either 
general for any associated diseases or local examination.  
 Standard laboratory tests, such as complete blood counts (CBCs), coagulation 
profile, liver and kidney function.  

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 The steps for follicular unit extraction donor site harvest are as follows: 
o We will shave the donor site to a depth of 0.5 to 1.5 mm to visualize the 
angle of the follicles. 
o Then while the patient in a prone, supine, or lateral position we do clean 
the area with povidone-iodine or chlorhexidine solution. 
o We Administer anesthesia beginning with regional nerve blocks—
supraorbital, supratrochlear, zygomaticofrontal, and occipital—followed 
by tumescent infiltration of the donor and recipient areas using a solution 
composed of 30 mL 2% lignocaine mixed with 5 mL 0.5% bupivacaine, 30 
mL normal saline, 0.5 mL of epinephrine 1 mg/mL, and 1 mL of 
triamcinolone 40 mg/mL in a normal adult patient. 
o Then we start Harvesting follicular units with a motorized sharp punch. 
 We calculate the desired total number of grafts needed by multiplying the 
measured recipient area by the desired graft density. The target density should be 
approximately 30 follicular units/cm². 
 We store grafts in storage solution (cold saline) put at gauze during procedure 
time. 
 Under magnification, we create recipient sites in a random and irregular pattern 
using either flat-edged blades or a combination of 19- or 21-gauge needles. 
 We Place the graft gently into the recipient site, applying light pressure for several 
seconds using a wet cotton-tip applicator to promote hemostasis and prevent graft 
extrusion or popping. 
 Then according to the groups we add the adjuvant therapy (first dose at the time of 
procedure) 
o PRP injection in group B 
o Nanofat injection in group C 
 We inject 0.1cc for every square centimeter in the recipient scalp with second 
dose one week postoperative. 
 The first follow up 2 days post-operative, then one week. 
 All patients will be followed up about 6-12 months postoperative. 
 Statistical analysis: 
• 
   Statistical analysis will be done using Statistical Package for the Social 
Sciences (SPSS) for Windows version 17.0.     
• 
Numerical data, such as age and duration of hospital stay, will be expressed as 
arithmetical mean ± SD , 
• 
Categorical data will be expressed as frequencies and percentages  

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• 
The percentages of various outcome variables will be compared by employing 
chi-square test & t-test: 
• 
 P value < 0.05 will be considered significant.  
• 
P value < 0.01 will be considered highly significant.  
• 
P value < 0.001 will be considered very highly significant. 
Ethical considerations : 
• 
Informed consent will be taken from all cases with approval of photo 
documentation. 
• 
Ethical approval will be taken from the scientific ethics committee. 
 

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References: 
 
1. Lolli, F.; Pallotti, F.; Rossi. A.; Fortuna, M.C.; Caro, G.; Lenzi, A.; Sansone, A. 
and Lombardo, F. (2017): Androgenetic alopecia: a review. Endocrine, 57(1):9-17.  
 
2. Sasaki, G.H. (2019): Review of Human Hair Follicle Biology: Dynamics of 
Niches and Stem Cell Regulation for Possible Therapeutic Hair Stimulation for 
Plastic Surgeons. Aesthetic Plast. Surg., 43(1):253-266.  
 
3. Neuhaus, K.; Schiestl, C.; Adelsberger, R.; Weibel, L.; Meuli, M. and Böttcher-
Haberzeth, S.(2019): Bold to do - bald to be? Outcomes decades after harvesting the 
scalp in burned children. Burns, 45(3):543-553.  
 
4. Almohanna, H.M.; Perper, M. and Tosti, A. (2018): Safety concerns when using 
novel medications to treat alopecia. Expert Opin. Drug Saf., 17(11):1115-1128.  
 
 
5. Goldin, J.; Zito, P.M. and Raggio, B.S. (2025): Hair Transplantation. In: StatPearls 
[Internet]. Treasure Island (FL): StatPearls Publishing. 
6. Price, V.H.(1999): Treatment of hair loss. N Engl. J Med., 341(13):964-73.  
7. Ajithkumar, K. and Parvathy, S. (2022): Pathogenesis of Androgenetic Alopecia. 
Review Article .Clinical Dermatology Review, 6(2):69-74. 
8. S. Okuda Okuda, S. and Jpn, J. (1939): Clinical and experimental studies of 
transplantation of living hairs. Dermatol. Urol., 46: 537-587. 
 
9. Joshi, R.; Shokri, T.; Baker, A.; Kohlert, S.; Sokoya, M.; Kadakia, S.; Epstein, J.; 
Ducic, Y. and Johnson, R.M. (2019): Alopecia and techniques in hair restoration: an 
overview for the cosmetic surgeon. Oral Maxillofac. Surg.,  23(2):123-131.   
10. Jimenez, F. and Ruifernández, J.M.(1999): Distribution of human hair in follicular 
units. A mathematical model for estimating the donor size in follicular unit 
transplantation. Dermatol. Surg., 25(4):294-298.  
11.Garg, S. (2016): Outcome of intra-operative injected platelet-rich plasma therapy 
during follicular unit extraction hair transplant: A prospective randomized study in 
forty patients. Journal of Cutaneous and Aesthetic Surgery, 9(3):157. 
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