Hair Restoration: A Regenerative Medicine Approach by Dr Alan Bauman at GAC2022 Miami.pdf

HAIR RESTORATION:
A REGENERATIVE MEDICINE APPROACH
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Hair Restoration: A Regenerative Medicine Approach | Alan J Bauman, MD
ALAN J BAUMAN, MD, ABHRS

GX Sciences, Inc.
Transdermal Cap, Inc.
Merck & Co., Inc.
Church & Dwight, Inc.
HairScience, LLC
Rion, LLC
HairCoach®
Certification/Training Program
Bauman Medical
⚠FDA: Off-Label Treatments will be discussed
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Objectives
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Hair Follicle Anatomy/Physiology
Hair Loss Pathophysiology
Principles of Regenerative Medicine (Cells, Signals & Scaffolds)
Regenerative Medicine in Hair Restoration
PRP - Principles & Best Practices
ECM - Role of Extracellular Matrix Scaffold
PDO - Polydioxanone, a Synthetic ECM Scaffold
Exosomes/EVs, Growth Factors & Stem Cells
TED Transepidermal Delivery - Ultrasonic Sound Waves
Regenerative Medicine & Hair Transplants
Future Therapies: Bioengineeing Hair Follicles

Multifactorial Pathophysiology of Alopecia
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EXTRINSIC
UV, Heat,
Toxins, Chemicals
Styling, Mechanical Forces
Sadick
N
et
al
(2017).
J
Drugs
and
Dermatol
11:135-140
SCALP HEALTH
+
OVERALL HEALTH
↓
HAIR GROWTH
INTRINSIC
Genetics
Inflammation
Hormones
Ilness/Fever
Stress/Cortisol
Nutritional Deficiencies
Mitochondrial Dysfunction
Stem Cell “Escape”
Senescence

Hair Follicle Miniaturization in Androgenetic Alopecia
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MINIA
TURIZING
shorter
thinner
weaker
wispier
depigmented
Genetics
Meds
Illness
Nutrition
Stress
Hormones
Inflammation
etc.

Hair Follicle Cycle Timing:
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Anagen
Catagen
Telogen

Human Hair Follicle Stem Cells & Cycling
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Cotsarelis G. Gene expression profiling gets to the root of human hair follicle stem cells. J Clin Invest. 2006;116(1):19–22. doi:10.1172/JCI27490
DERMAL PAPILLA
(Proliferating
Progenitor Cells)
BULGE
(Stem Cells)
Dermal Papilla

Hair Follicle Stem Cell Niche & Signaling
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Ya-Chieh Hsu & Elaine Fuchs; A family business: stem cell progeny join the niche to regulate homeostasis, Nature Reviews Molecular Cell Biology 13, 103-114 (February 2012) doi:10.1038/nrm3272
Hair Follicle
Stem Cell Niche:
Bul
g
e
Dermal Papilla
Dermal Fibroblasts
Adipocytes

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Growth Factor Functions in Hair Follicle Cycling
IGF-1
Major mediator of growth hormone stimulated somatic growth
and GH-independent anabolic responses.
IGF-2
Major mediator of growth hormone stimulated somatic growth
and GH-independent anabolic responses.
aFGF
Stimulates hair growth by beta-Catenin expression and inducing
the anagen phase in resting hair follicles.
bFGF
Stimulates hair growth by beta-Catenin expression and inducing
the anagen phase in resting hair follicles.
KGF
Binds to KGF receptor to stimulate hair growth. Stimulates
epithelia cell proliferation, differentiation, and migration and
promotes a number of cell protective mechanisms.
KGF-2
Binds to KGF receptor to stimulate hair growth. Stimulates
epithelia cell proliferation, differentiation, and migration and
promotes a number of cell protective mechanisms.
SCF
Expression of stem cell factor necessary for the maintenance of
differentiated melanocytes and hair pigmentation.
CSF-1
Immunomodulatory cytokine that regulates cell proliferation and
differentiation, and may play important role in regulating hair growth.
PDGF-a
Plays a role in stimulating the proliferation of dermal mesenchymal
cells that contribute to the formation of the dermal papillae.
EPO
Promotes hair shaft growth and modulation by stimulating dermal
papilla cells.
Noggin Cellular signaling required for anagen induction.
CG-VEGF
Strongest regulator of physiological angiogenesis, induces
proliferation of human hair follicle dermal papilla cells.

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REGENERATIVE
MEDICINE &
TISSUE
ENGINEERING?
SCAFFOLDS
SIGNALS
WHAT IS THE “TROIKA” OF
CELLS

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REGENERATIVE
MEDICINE
TISSUE
ENGINEERING
SCAFFOLDS
CLINICIAN/
SCIENTIST
SIGNALS
CELLS

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Extracellular Vesicles
TISSUE
ENGINEERING
&
REGENERATIVE
MEDICINE
SCAFFOLDS
SIGNALS
CELLS
THE TRIAD OF TISSUE
ENGINEERING &
REGENERATIVE MEDICINE:
The combination of cells, signals, &
scaffolds is used to regenerate,
replace, augment, or engineer
functional tissues.
Electromagnetic Spectrum

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Extracellular Vesicles
REGENERATIVE
MEDICINE STRATEGIES IN
HAIR RESTORATION
SCAFFOLDS
SIGNALS
CELLS
MSCs
Mesenchymal
Stem Cells /
Medicinal
Signaling Cells,
PRP/PRF
Growth Factors,
Peptides, EVs,
Photobiomodulation,
Mechanical
Forces…
ECM
Extracellular Matrix:
Biologic &
Synthetic

Regenerative Strategies in Hair Restoration
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Regenerative Strategies in Hair Restoration
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Adult Stem Cells
Adipose Derived Stem Cells (ADSC)
Nanofat, Stromal Vascular Fraction (SVF)
Hair Follicle Stem Cells (HFSCs) -
autologous or cultured
Bone Marrow Derived
Perinatal Stem Cells
Umbilical Cord Blood Derived
Wharton’s Jelly MSCs
Amniotic Fluid Derived
Placental MSCs
Peptides & Growth Factors
Ultrasonic Sound Waves - TED
RF Radiofrequency
Pulsed Electromagnetic Fields - PEMF
Photobiomodulation - Laser or LEDs
Extracellular Matrix
xenograft, allograft, synthetic (PDO)
Platelet Rich Plasma (PRP/PRF)
Conditioned Media
ADSC-CM, hUBC-CM, HF-CM, BM-CM
Extracellular Vesicles - EVs
Exosomes - newborn foreskin SCs, DPC,
BM-MSC, Platelet-derived exosomes
Exosome-like (ginseng, ashwaghanda)
Microvesicles
Hair Follicle Multiplication - IPSCs

PRP Platelet Rich Plasma
w/ ECM Extracellular
Matrix
for
Hair Regrowth
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PRP
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PRP/PRF Challenges
• Preparation Techniques Vary Greatly
• What dose (i.e., platelet concentration, volume)
• Monocytes?
• Application Techniques
• Contraindications rarely tracked (NSAIDs, etc)
• Use of ECM extracellular matrix uncommon
• Poor Measurement / Tracking
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Takahashi Y, Nishikawa M, Shinotsuka H, et al. Visualization and in vivo tracking of the exosomes of murine melanoma B16-BL6 cells in mice after intravenous injection. J Biotechnol. 2013;165(2):77-84. doi:10.1016/j.jbiotec.2013.03.013
Patel, G.K., Khan, M.A., Zubair, H. et al. Comparative analysis of exosome isolation methods using culture supernatant for optimum yield, purity and downstream applications. Sci Rep 9, 5335 (2019). https://doi.org/10.1038/s41598-019-41800-2

Pathways of PRP Hair Folliculogenesis & Cycling
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BAD - Bcl-2-associated death protein
BAX - Bcl-2-associated X protein
ERK - extracellular signal-related kinases
MAPK - mitogen-activated protein kinases
PDGF - platelet-derived growth factor
PIP2 - phosphatidylinositol 4,5-biphosphate
PIP3 - phosphatidylinositol 3,4,5-triphosphate
PRP - platelet-rich plasma
B Singh, LJ Goldberg, Autologous Platelet-Rich Plasma for the Treatments of Pattern Hair Loss, Am J Clin Dermatol (2016) 17:359-367 DOI 10.1007/s40257-016-0196-2

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Haynesworth et al, 2002 48th Annual Meeting of the Orthopedic Research Society
MSC Behavior & Vascular Neogenesis?

PRP Quality Testing
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What’s In YOUR PRP?
PLT: >1,600,000 plt/µl
Platelet Concentration Factor = 6.3x
Whole Blood: 253,000 plt/µl
~1.5 M plt/µl
Low Erythrocyte
Low Granulocyte
High Monocyte
Dual-Spin PRP Quality Testing

Systematic Review of Platelet-Rich Plasma Use in
Androgenetic Alopecia Compared with Minoxidil®,
Finasteride®, and Adult Stem Cell-Based Therapy
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12 Studies ultimately included by Dr. P. Gentile:
84% demonstrated positive effect of PRP on AGA
50% demonstrated statistically signi
fi
cant objective
endpoints (hair density and hair thickness)
No Major Side Effects reported in any study
Only one study showed no improvement
•Gentile, P.; Garcovich, S. Systematic Review of Platelet-Rich Plasma Use in Androgenetic Alopecia Compared with Minoxidil®, Finasteride®, and Adult Stem Cell-Based
Therapy. Int. J. Mol. Sci. 2020, 21, 2702. https://doi.org/10.3390/ijms21082702

Extracellular Matrix Scaffolds Ex Vivo & In Vivo:
Surgical Xenografts, Allografts & Synthetics to Regenerate & Replace
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SIS Porcine
Small
Intestine
Submucosa
UBM Porcine
Urinary
Bladder
Matrix
PDO/PEG
Synthetic
Surgical Mesh
Human Placenta
Tissue Matrix
Decellularized Cardiac Tissue
Implantation of
Decellularized
Porcine
Pulmonary Valve
Chondrogenic differentiation of bone marrow-derived mesenchymal stem cells induced by acellular cartilage sheets. Xue JX, Gong YY, Zhou GD, Liu W, Cao Y, Zhang WJ Biomaterials. 2012 Aug; 33(24):5832-40.
Tricuspid Valve: Unlocking the secrets to regenerating cardiac tissue: an update Olga N. Kislitsina Interactive CardioVascular and Thoracic Surgery 26 (2018) 146–154 STATE-OF-THE-ART doi:10.1093/icvts/ivx264

ECMs in Hair Restoration
• PRP + Porcine Xenograft (ACell - Porcine
Bladder) - J. Cooley, G. Hitzig, others
• PRP + Human Placental Allograft - “Novel
Use of Cryopreserved Human Amniotic
Membrane Allograft in Hair Restoration”
- A.Bauman 2015 ISHRS Annual Meeting
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Morselized Human Placental Tissue ECM
A N O V E L U S E O F C R Y O G E N I C A L LY P R E S E R V E D A M N I O N I C
E X T R A C E L L U L A R M AT R I X W I T H P R P F O R H A I R R E G R O W T H
INTRODUCTION
Medical interventions to halt or reverse hair loss such as topical minoxidil, oral finasteride, low level laser therapy have been used to help patients suffering from androgenetic alopecia. The benefits of PRP platelet rich plasma as an adjunct to hair transplantation and as a stand-alone
therapy for alopecia areata and androgenetic alopecia have been suggested in a number of recently published scholarly articles, lectures and reports but still remain anecdotal.
Over the past few decades, the clinical use of PRP or platelet rich plasma has grown in popularity amongst many segments of the medical profession such as periodontics and restorative dentistry, ent, plastic surgery, orthopedics, neurosurgery, cardiovascular and cardiothoracic surgery,
general surgery, hair transplant surgery and more. In humans, PRP has been investigated and used as an adjunctive or alternative treatment for hard and soft tissue healing and regeneration in cases of nerve injury, tendinopathies, myocardial injury, bone repair and regeneration, wound
healing and cosmetic procedures such as facial rejuvenation and the treatment of hair loss. Unfortunately, a lack of standardization as well as variations in preparation, application, patient selection and measurement methods have resulted in both negative and positive clinical trial
outcomes—mandating the need for further study.
PLATELET RICH PLASMA PRP
Produced in just minutes from a small quantity of the patient’s own blood, PRP contains a wide variety of the body’s own natural growth factors, cytokines and other components which have been implicated in accelerating tissue regeneration, improving wound healing time, attracting stem
cells, initiating angiogenesis as well as affecting hair follicle cycling. Early studies suggest that platelet derived growth factors stimulate cellular proliferation at the dermal papilla, prolong the anagen phase and delay the telogen phase of the hair follicle, as well as accelerate hair growth.
Platelets are cell fragments found in the blood that play a key role in blood clotting and are a natural source of powerful growth factors capable of stimulating cellular growth, proliferation, healing, and cellular differentiation. A variety of centrifuges and PRP preparation kits are available to be
used at the bedside to carefully and gently separate platelets from a small sample of blood and prepare them for use. Once applied and activated, platelets degranulate and release their stores of influential growth factors, cytokines, chemokines and other molecules. Platelets contain
powerful protein molecules called growth factors that normally begin tissue repair and regeneration at a wound site by initiating connective tissue healing, bone regeneration and repair, promote development of new blood vessels, and stimulate the wound healing process. Many growth
factors have also been implicated in the cascade of cellular events that occur when hair follicles are treated with medications to stimulate hair growth. Some of the growth factors and components found in PRP that may influence hair follicles include: EGF, epidermal growth factor; TGF-β,
transforming growth factor-alpha; IGF-1, insulin-like growth factor-1; VEGF, vascular endothelial growth factor; PDGF, platelet derived growth factor; FGF, Fibroblast Growth Factors; Ang-2, angiopoietin-2; IL-1, interleukin-1 beta; and more.
Many of the pitfalls for proper evaluation derive from the fact that the use of PRP varies from physician to physician -- not all PRP’s are “created equal”-- and each physician has their own patient-selection, preparation and application protocols. During a minimally invasive Follicular Unit
Extraction FUE hair transplant procedure, PRP may be applied topically to the donor and/or recipient areas. It can be also be used for hemostasis during more invasive hair transplant procedures. PRP also makes for a unique physiologic graft-storage medium in which the follicles are kept
outside of the body while they await transplantation. During a cosmetic or reconstructive procedure, like hair transplantation, PRP is commonly applied to soft tissue grafts to stabilize the graft material and enhance the ‘take’ of the grafts as well as to seal wounds and accelerate soft tissue
healing. In this way, PRP may enhance the results from a hair transplant procedure (C Uebel, R Reese) or rejuvenate hair follicles as a stand-alone therapy which, over time, would require re-treatment. (Amgar, Bouhanna, Rinaldi, Greco)
ROLE OF EXTRACELLULAR MATRIX ECM
In animals, the extracellular matrix or ECM is the extracellular part of a multicellular structure that typically provide structural and biochemical support to the surrounding cells. Essential for processes like growth, wound healing and fibrosis, ECM can serve many functions such as providing
support, segregating tissues and regulating intercellular communication. In terms of injury repair or tissue engineering, ECM performs two main functions. First, is prevents the immune system from triggering from the injury and responding with inflammation and scar tissue. Next, it
facilitates the surrounding cells to repair the tissue instead of forming scar tissue.
PRP protocols for hair regrowth without ECM tend to include re-treatment within weeks or months. The use of ECM biomaterial products in combination with PRP have been reported to enhance the results of PRP treatments in terms of strength and duration. One such product is acellular
porcine urinary bladder matrix. Devoid of cells, it is provided in a micronized powder designed to maintain and support a constructive healing environment by promoting the formation of site-specific tissue. It contains basement membrane, collagen and provides a scaffold for natural
ABOUT THE AUTHOR
Dr. Alan J. Bauman received his M.D. degree from New York
Medical College and his surgical training at Mt. Sinai Medical
Center and Beth Israel Medical Center in NY before
specializing exclusively in hair transplant surgery and the
treatment of hair loss. He is a Fellow of the International
Society of Hair Restoration Surgery and a Diplomate of the
American Board of Hair Restoration Surgery. Dr. Bauman is
the Founder and Medical Director of Bauman Medical, located
in Boca Raton, FL since 1997.
The following conflicts of interest are relevant to this
presentation: NONE
REFERENCES
Hordinsky MK, Sundby S. The effect of activated platelet supernatant on synthesis of hair protein and DNA in microdissected human hair follicles.
Ann N Y Acad Sci. 1991 Dec 26;642:465-7.
Marx RE, et al, “Platelet-Rich Plasma Growth Factor Enhancement for Bone Grafts,” Oral Surg Oral Med Oral Patrhol, 1998;85:638-646.
Antonaides HN, et al, ”Human Platelet-Derived Growth Factor: Structure and Functions”, Federation Proceedings, 1983;42:2630-2634.
Pierce GF, et al, ”PDGF-BB,TGF-β 1 and Basic FGF in Dermal Wound Healing: Neovessel and Matrix Formation and Cessation Repair”, Am J
Pathology, 1992;140:1375-1388.
Bauman AJ, The use of cross-sectional hair bundle trichometry in the diagnosis, evaluation and tracking of hair loss. Poster Presentation. ISHRS
Annual Scientific Meeting, October 2012 Nassau, Bahamas.
Gruss, J., et.al., Human amniotic membrane: a versatile wound dressing. CMA Journal 1978; Vol.118:1237-1246.
ALAN J BAUMAN, MD, ABHRS
B OCA R ATON, F L
HAIR GROWTH CHANGES OVER TIME AFTERPRP WITH AND WITHOUT AMNIONIC ECM
A comparison of percent increase in hair diameter after PRP without ECM (previously reported by Amgar, Bouhanna)
to change in hair mass index over time in months using PRP with amnionic ECM.
Time (months)
A N O V E L U S E O F C R Y O G E N I C A L LY P R E S E R V E D A
E X T R A C E L L U L A R M AT R I X W I T H P R P F O R H A I R R E
INTRODUCTION
Medical interventions to halt or reverse hair loss such as topical minoxidil, oral finasteride, low level laser therapy have been used to help patients suffering from androgenetic alopecia. The benefits of PRP platelet rich plasma as an adjunct to hair transplantation and as a stand-alone
therapy for alopecia areata and androgenetic alopecia have been suggested in a number of recently published scholarly articles, lectures and reports but still remain anecdotal.
Over the past few decades, the clinical use of PRP or platelet rich plasma has grown in popularity amongst many segments of the medical profession such as periodontics and restorative dentistry, ent, plastic surgery, orthopedics, neurosurgery, cardiovascular and cardiothoracic surgery,
general surgery, hair transplant surgery and more. In humans, PRP has been investigated and used as an adjunctive or alternative treatment for hard and soft tissue healing and regeneration in cases of nerve injury, tendinopathies, myocardial injury, bone repair and regeneration, wound
healing and cosmetic procedures such as facial rejuvenation and the treatment of hair loss. Unfortunately, a lack of standardization as well as variations in preparation, application, patient selection and measurement methods have resulted in both negative and positive clinical trial
outcomes—mandating the need for further study.
PLATELET RICH PLASMA PRP
Produced in just minutes from a small quantity of the patient’s own blood, PRP contains a wide variety of the body’s own natural growth factors, cytokines and other components which have been implicated in accelerating tissue regeneration, improving wound healing time, attracting stem
cells, initiating angiogenesis as well as affecting hair follicle cycling. Early studies suggest that platelet derived growth factors stimulate cellular proliferation at the dermal papilla, prolong the anagen phase and delay the telogen phase of the hair follicle, as well as accelerate hair growth.
Platelets are cell fragments found in the blood that play a key role in blood clotting and are a natural source of powerful growth factors capable of stimulating cellular growth, proliferation, healing, and cellular differentiation. A variety of centrifuges and PRP preparation kits are available to be
used at the bedside to carefully and gently separate platelets from a small sample of blood and prepare them for use. Once applied and activated, platelets degranulate and release their stores of influential growth factors, cytokines, chemokines and other molecules. Platelets contain
powerful protein molecules called growth factors that normally begin tissue repair and regeneration at a wound site by initiating connective tissue healing, bone regeneration and repair, promote development of new blood vessels, and stimulate the wound healing process. Many growth
factors have also been implicated in the cascade of cellular events that occur when hair follicles are treated with medications to stimulate hair growth. Some of the growth factors and components found in PRP that may influence hair follicles include: EGF, epidermal growth factor; TGF-β,
transforming growth factor-alpha; IGF-1, insulin-like growth factor-1; VEGF, vascular endothelial growth factor; PDGF, platelet derived growth factor; FGF, Fibroblast Growth Factors; Ang-2, angiopoietin-2; IL-1, interleukin-1 beta; and more.
Many of the pitfalls for proper evaluation derive from the fact that the use of PRP varies from physician to physician -- not all PRP’s are “created equal”-- and each physician has their own patient-selection, preparation and application protocols. During a minimally invasive Follicular Unit
Extraction FUE hair transplant procedure, PRP may be applied topically to the donor and/or recipient areas. It can be also be used for hemostasis during more invasive hair transplant procedures. PRP also makes for a unique physiologic graft-storage medium in which the follicles are kept
outside of the body while they await transplantation. During a cosmetic or reconstructive procedure, like hair transplantation, PRP is commonly applied to soft tissue grafts to stabilize the graft material and enhance the ‘take’ of the grafts as well as to seal wounds and accelerate soft tissue
healing. In this way, PRP may enhance the results from a hair transplant procedure (C Uebel, R Reese) or rejuvenate hair follicles as a stand-alone therapy which, over time, would require re-treatment. (Amgar, Bouhanna, Rinaldi, Greco)
ROLE OF EXTRACELLULAR MATRIX ECM
In animals, the extracellular matrix or ECM is the extracellular part of a multicellular structure that typically provide structural and biochemical support to the surrounding cells. Essential for processes like growth, wound healing and fibrosis, ECM can serve many functions such as providing
support, segregating tissues and regulating intercellular communication. In terms of injury repair or tissue engineering, ECM performs two main functions. First, is prevents the immune system from triggering from the injury and responding with inflammation and scar tissue. Next, it
facilitates the surrounding cells to repair the tissue instead of forming scar tissue.
PRP protocols for hair regrowth without ECM tend to include re-treatment within weeks or months. The use of ECM biomaterial products in combination with PRP have been reported to enhance the results of PRP treatments in terms of strength and duration. One such product is acellular
porcine urinary bladder matrix. Devoid of cells, it is provided in a micronized powder designed to maintain and support a constructive healing environment by promoting the formation of site-specific tissue. It contains basement membrane, collagen and provides a scaffold for natural
remodeling and complements. Hair restoration physicians J Cooley, J Cole and others have described this ECM’s hair regenerative and wound healing properties in publications and lectures.
HUMAN AMNIONIC ALLOGRAFT AS AN ALTERNATIVE ECM
For centuries, the healing benefits of amniotic tissues have been described. Often characterized as “immune privileged,” the amniotic membrane rarely evokes an immune response in human tissue. Amniotic tissue also contains multipotent cells that are capable of differentiating into all
three germ layers of the human body. Amniotic derived stem cells have been shown to be broadly multipotent, capable of differentiating into adipogenic, osteogenic, myogenic, endothelial, neurogenic and hepatic cell lineages. BioD-Restore (BioD, Memphis) is a structural allograft derived
from human amnion and can be used as an alternative to synthetic, cadaveric or animal-derived regenerative medicine products. Because it is morselized and cryopreserved (not dehydrated compared to other extracellular matrix products) it contains the native architecture of the
extracellular matrix and maintains the quantity and activity of key biological signals present in fresh amnion. The presence of chemical compounds, growth factors and residual cells naturally present in amnion may provide ancillary clinical benefits by enhancing the body’s natural
regenerative process. Once thawed, this flowable ECM can be easily suspended in PRP prior to use.
REGULATORY ISSUES, RISKS, PROCUREMENT/PROCESSING OF AMNIONIC ECM
Donors are prescreened via strict medical review and prenatal testing, behavioral risk assessment, blood test results, medical history and disease testing. Tissue is procured via aseptic recovery during live birth sterile cesarean section—instead of being discarded—and is transported to an
FDA-registered tissue bank for processing. Culturing and toxicity testing is performed prior to lot release of the FDA-registered tissue. No cloned cells or fetal demise tissue is utilized. Possible adverse effects of using human tissues include but are not limited to infection, disease
transmission and undesirable immune response.
POTENTIAL BENEFITS OF CRYOPRESERVED AMNIONIC ECM
Supporting Soft Tissue Repair - Extracellular matrix composition of Collagens I, III, IV, V, VII and other structural proteins provides a natural scaffold to facilitate cellular adhesion while assisting cellular migration and proliferation.
Promote Soft Tissue Reconstruction - Growth factors found in amniotic tissue such as PDGF, VEGF, EGF, FGF and TGF-B promote cellular proliferation and new collagen formation.
Reduce Inflammation and Pain - Interleukin-1 receptor antagonists (IL-1RA) and Tissue Inhibitor of Metalloproteinase (TIMP) 1, 2, 3, 4 proteins present in amniotic tissues suppress and modulate inflammation and pain.
SIDE-EFFECTS AND SEQUELAE
Post-treatment, mild tenderness and swelling in the treated area is common. Within 72 hours, edema may progress in a gravity-dependent manner to the forehead in rare cases before resolving. Bruising from the treatment is rare but if it occurs, it can be expected to last about one week.
Mild tenderness, bruising and swelling at the phlebotomy site can also be expected. Follow-ups for cross-sectional hair bundle trichometry measurements and dermoscopy are typically scheduled at 12 week intervals to track hair growth and determine the timing of re-treatment.
CASE REPORT
31yo Male w/ AGA was treated with PRP plus amniotic ECM [as described in “Methods”] with no other treatments. His HMI increase was noted at 6 and 12 weeks and was sustained for more than 9 months, compared to PRP alone (Amgar, Bouhanna, Greco) which increased hair caliber
for a duration of 3-4 months. Global and microscopic photos at 9 months were compared to baseline.
DISCUSSION & CONCLUSION
While certainly not replacing the need for hair transplantation in severely depleted areas, PRP’s reported benefits may help patients reduce and/or delay the need for extensive surgical intervention(s). The author has described a novel use of a cryogenically preserved amnionic ECM which
may, as reported with other ECMs, have the desirable potential to safely and effectively increase and prolong the hair regrowth properties of PRP treatments for androgenetic alopecia—warranting further scientific investigation and larger controlled studies. The author encourages others
interested in PRP with ECM for AGA to collaborate on standardized processing procedures, application methods and follow-up tracking and assessment protocols.
GROWTH FACTORS &
OTHER COMPONENTS FOUND IN PRP
platelet-derived growth factor
transforming growth factor beta
fibroblast growth factor
insulin-like growth factor 1
insulin-like growth factor 2
vascular endothelial growth factor
epidermal growth factor
interleukin-8
keratinocyte growth factor
connective tissue growth factor
very small embryonic-like (VSEL) stem cells
METHOD: STEPS INVOLVED WITH PRP HAIR REGROWTH TREATMENT WITH ECM
1) Patients with focal alopecia areata or androgenetic alopecia are selected and informed consent obtained.
2) The degree of hair loss and the amount of miniaturized hair is evaluated, photographed and quantified.
3) Scalp is prepped using antiseptic shampoo.
4) The treatment area is measured with HairCheck (Iberius, Miami) cross-sectional bundle trichometry.
5) Phlebotomy is performed.
6) Scalp treatment area is anesthetized with ring block of 2% articaine 1:100,000 epinephrine.
7) PRP is prepared using YesPRP kit and centrifuge (Zizion Group, Boca Raton) for 9min @1300G / 2800rpm.
8) BioD-Restore cryopreserved amnionic ECM (BioD, Memphis) is thawed.
9) PRP is gently mixed with ECM in a syringe.
10) PRP+ECM mixture is injected intradermally into the scalp throughout the treatment area.
11) AmeiaMed (Jernigan Medical, Orlando) microneedling device is used in the treatment area.
12) Scalp is cleansed, post-treatment instructions are provided.
13) Follow-up appointments are scheduled prior to discharge.
ASSESSMENT
Hair Mass Index (HMI) was measured in the treatment area at baseline and at 90 day intervals using HairCheck
cross sectional hair bundle trichometry. Global and dermoscopic photos at 9 months were compared to baseline.
REFE
Hordin
Ann N
Marx R
Anton
Pierce
Patho
Baum
Annua
Gruss
De Co
Bouha
Bouha
Amga
31-41.
Sciafa
matrix
Takak
format
Yano K
Rinald
hair gr
Sharo
Derma
Li M,
possib
Mak K
Rosen
ligand
Weger
Mak K
Univer
Sorbe
treatm
Takika
2011;
Greco
Transp
Uebel
Surg 2
Greco
Interna
Reese
transp
Amga
Amga
Akle C
Josep
Modes
Res 2
Solom
vitro m
Koizum
memb
Peters
Resea
Gruss
De Co
Renni
biolog
For m
A
B O
GLOBAL PHOTOGRAPHY AT BASELINE AND 9MOS AFTER PRP+ECM
ALAN J BAUMAN, MD
ALAN J BAUMAN, MD
PRP PREPARATION WITH ECM USING STERILE TECHNIQUE
Time (months)
GLOBAL PHOTOGRAPHY AT BASELINE AND 9MOS AFTER PRP+ECM
N O V E L U S E O F C R Y O G E N I C A L LY P R E S E R V E D A M
X T R A C E L L U L A R M AT R I X W I T H P R P F O R H A I R R E G
se hair loss such as topical minoxidil, oral finasteride, low level laser therapy have been used to help patients suffering from androgenetic alopecia. The benefits of PRP platelet rich plasma as an adjunct to hair transplantation and as a stand-alone
ogenetic alopecia have been suggested in a number of recently published scholarly articles, lectures and reports but still remain anecdotal.
cal use of PRP or platelet rich plasma has grown in popularity amongst many segments of the medical profession such as periodontics and restorative dentistry, ent, plastic surgery, orthopedics, neurosurgery, cardiovascular and cardiothoracic surgery,
ery and more. In humans, PRP has been investigated and used as an adjunctive or alternative treatment for hard and soft tissue healing and regeneration in cases of nerve injury, tendinopathies, myocardial injury, bone repair and regeneration, wound
ch as facial rejuvenation and the treatment of hair loss. Unfortunately, a lack of standardization as well as variations in preparation, application, patient selection and measurement methods have resulted in both negative and positive clinical trial
urther study.
ll quantity of the patient’s own blood, PRP contains a wide variety of the body’s own natural growth factors, cytokines and other components which have been implicated in accelerating tissue regeneration, improving wound healing time, attracting stem
as affecting hair follicle cycling. Early studies suggest that platelet derived growth factors stimulate cellular proliferation at the dermal papilla, prolong the anagen phase and delay the telogen phase of the hair follicle, as well as accelerate hair growth.
the blood that play a key role in blood clotting and are a natural source of powerful growth factors capable of stimulating cellular growth, proliferation, healing, and cellular differentiation. A variety of centrifuges and PRP preparation kits are available to be
gently separate platelets from a small sample of blood and prepare them for use. Once applied and activated, platelets degranulate and release their stores of influential growth factors, cytokines, chemokines and other molecules. Platelets contain
owth factors that normally begin tissue repair and regeneration at a wound site by initiating connective tissue healing, bone regeneration and repair, promote development of new blood vessels, and stimulate the wound healing process. Many growth
the cascade of cellular events that occur when hair follicles are treated with medications to stimulate hair growth. Some of the growth factors and components found in PRP that may influence hair follicles include: EGF, epidermal growth factor; TGF-β,
F-1, insulin-like growth factor-1; VEGF, vascular endothelial growth factor; PDGF, platelet derived growth factor; FGF, Fibroblast Growth Factors; Ang-2, angiopoietin-2; IL-1, interleukin-1 beta; and more.
tion derive from the fact that the use of PRP varies from physician to physician -- not all PRP’s are “created equal”-- and each physician has their own patient-selection, preparation and application protocols. During a minimally invasive Follicular Unit
dure, PRP may be applied topically to the donor and/or recipient areas. It can be also be used for hemostasis during more invasive hair transplant procedures. PRP also makes for a unique physiologic graft-storage medium in which the follicles are kept
transplantation. During a cosmetic or reconstructive procedure, like hair transplantation, PRP is commonly applied to soft tissue grafts to stabilize the graft material and enhance the ‘take’ of the grafts as well as to seal wounds and accelerate soft tissue
ce the results from a hair transplant procedure (C Uebel, R Reese) or rejuvenate hair follicles as a stand-alone therapy which, over time, would require re-treatment. (Amgar, Bouhanna, Rinaldi, Greco)
X ECM
ECM is the extracellular part of a multicellular structure that typically provide structural and biochemical support to the surrounding cells. Essential for processes like growth, wound healing and fibrosis, ECM can serve many functions such as providing
ulating intercellular communication. In terms of injury repair or tissue engineering, ECM performs two main functions. First, is prevents the immune system from triggering from the injury and responding with inflammation and scar tissue. Next, it
pair the tissue instead of forming scar tissue.
out ECM tend to include re-treatment within weeks or months. The use of ECM biomaterial products in combination with PRP have been reported to enhance the results of PRP treatments in terms of strength and duration. One such product is acellular
d of cells, it is provided in a micronized powder designed to maintain and support a constructive healing environment by promoting the formation of site-specific tissue. It contains basement membrane, collagen and provides a scaffold for natural
estoration physicians J Cooley, J Cole and others have described this ECM’s hair regenerative and wound healing properties in publications and lectures.
AS AN ALTERNATIVE ECM
amniotic tissues have been described. Often characterized as “immune privileged,” the amniotic membrane rarely evokes an immune response in human tissue. Amniotic tissue also contains multipotent cells that are capable of differentiating into all
y. Amniotic derived stem cells have been shown to be broadly multipotent, capable of differentiating into adipogenic, osteogenic, myogenic, endothelial, neurogenic and hepatic cell lineages. BioD-Restore (BioD, Memphis) is a structural allograft derived
d as an alternative to synthetic, cadaveric or animal-derived regenerative medicine products. Because it is morselized and cryopreserved (not dehydrated compared to other extracellular matrix products) it contains the native architecture of the
e quantity and activity of key biological signals present in fresh amnion. The presence of chemical compounds, growth factors and residual cells naturally present in amnion may provide ancillary clinical benefits by enhancing the body’s natural
this flowable ECM can be easily suspended in PRP prior to use.
METHOD: STEPS INVOLVED WITH PRP HAIR REGROWTH TREATMENT WITH ECM
1) Patients with focal alopecia areata or androgenetic alopecia are selected and informed consent obtained.
2) The degree of hair loss and the amount of miniaturized hair is evaluated, photographed and quantified.
3) Scalp is prepped using antiseptic shampoo.
4) The treatment area is measured with HairCheck (Iberius, Miami) cross-sectional bundle trichometry.
5) Phlebotomy is performed.
6) Scalp treatment area is anesthetized with ring block of 2% articaine 1:100,000 epinephrine.
7) PRP is prepared using YesPRP kit and centrifuge (Zizion Group, Boca Raton) for 9min @1300G / 2800rpm.
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Seo, Hyung-Sik et.al. (2015). The Success of Thread-embedding Therapy in Generating Hair Re-growth in Mice Points to Its Possibly Having a Similar Effect in Humans. Journal of Pharmacopuncture. 18. 20-25.
Enhanced anagen / Improved hair thickness
Increased BrdU expression: cellular proliferation
Proliferating cell nuclear antigen PCNA
Increased activity at bulge and dermal papilla
Upgregulation of hair follicular cell proliferation:
⬆︎
FGF-7 mRNA outer root sheath (anagen induction)
⬇FGF-5 mRNA (anagen cessation)
PDO threads enhanced anagen induction by upregulating cellular proliferation.
Hyun
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Cu-GHK, VEGF, Tβ4-derivative, Amino Acids,
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Lipoaspirate - SVF, nanofat added to PRP (Epstien/Kuka)
Adipose-Derived Conditioned Media (ADSC-CM) w/ Microneedling
Exosomes - Adipose-Derived Secretome
Fukuoka H, Narita K, Suga H. Hair Regeneration Therapy: Application of Adipose-Derived Stem Cells. Curr Stem Cell Res Ther. 2017; 12(7):531-534.
ADSC-CM - Conditioned Media
x 8 treatments (1/mo)

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Author Study Type Sample Size Results
Perez-Meza et al Pilot Case Series 9
Fat+SVF=↑31 hair/cm
FAT only=14 hair/cm
Aronowitz, et al Prospective, single blinded 9
14% ↑ in hair count; 34% ↑
in Anagen
Kim, et al Clinical Human Study 9
↑ Hair Density at 3 &6
Months; ↑Keratin score,
↑hair thickness
Stevens, et al Clinical Human Study 10 ↑Hair Density 6&12 wks
Anudeep, T.C.; Jeyaraman, M.; Muthu, S.; Rajendran, R.L.; Gangadaran, P.; Mishra, P.C.; Sharma, S.; Jha, S.K.; Ahn, B.-C. Advancing
Regenerative Cellular Therapies in Non-Scarring Alopecia. Pharmaceutics 2022, 14, 612. https://doi.org/10.3390/pharmaceutics14030612
Thank You: Dr Ryan Welter

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Shin, et at Retrospective, observational 27
↑ Density and
↑Thickenss
Fukuoka, et at Prospective Human Study 22 ↑ Hair Count

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Gentile, et al Prospective Human Study 11 29% ↑ Hair Density
Gentile, et al
Retrospective
Observational Case Study 33
33% ↑ Hair Density at wk 23; 27%
↑ at wk 44
Gentile, et al
Retrospective
Observational Case Study 21
30%↑ Hair Density 12 wks; 29%↑
at 23 wks
Gentile, et al
Placebo Controlled
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Improvement in mean hair count
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Oh, et al
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Sabapathy, et al Experimental - Mice
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maintained MSC Properties;
↑immunomodulatory molecules than
BM-MSC; WJ on accellular amniotic
membrane improved scar free wound
healing and hair growth
Czarnecka, et al
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Yoon, et al Experimental - Mice in vitro
Wound Healing
Study
AF-MSC's secrete high numbers
of cytokines and growth factors
which incresae wound healing;
Park, et al Experimental - Mice
Cultured Media from AF-MCS's ↑↑
Anagen; AF with overexpression
of Nanog ↑↑expression of DP and
HFSC Markers

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Courtesy: Kimera
• Exosomes = extracellular vesicles or “packets” 30-100nm
• Cell-to-Cell paracrine communication
• Protiens, Lipids, mRNAs (on), miRNA (off), metabolites
• EVs - tissue regeneration, immune modulation, promote
angiogenesis, biomarkers of disease & aging

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Exosomes in Hair Restoration | Alan J Bauman, MD
Adipose-Derived Stem Cell Exosomes Promoted Hair Regeneration.
Wu, J., et al. Tissue Eng Regen Med Aug;18(4):685-691. doi: 10.1007/s13770-021-00347-y.
Exosomes derived from human dermal papilla cells promote hair growth in cultured human
hair follicles and augment the hair-inductive capacity of cultured dermal papilla spheres.
Mi H. Kwack, et al. Exp Dermatol. 2019 Jul;28(7):854-857. doi: 10.1111/exd.13927.

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(Dr. Dan McGrath - TX)
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Exosomes in Hair Restoration | Alan J Bauman, MD
ADSC / NanoFat
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Ji, S., Zhu, Z., Sun, X. et al. Functional hair follicle regeneration: an updated review. Sig Transduct Target Ther 6, 66 (2021).
Lee, J., Rabbani, C.C., Gao, H. et al. Hair-bearing human skin generated entirely from pluripotent stem cells. Nature 582, 399–404 (2020).
3D Culture Lab-Grown Hair Follicle Organoids
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Japan: Human hair follicles derived from
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San Diego, CA: Researchers at Stemson
create new hair follicles using iPSCs.
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