Holding solutions for grafts... Hairtech

Hair Transplant
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Yet another debatable topic. Holding solutions are the solutions that the grafts are placed in to sort of “feed” the grafts, stabilize PH, and sometimes protect them from the elements. Some of the holding solutions are: Saline/BSS/DMEM/PLASMALYTE A/BSS with Glutathione/RINGERS LACTATE/ just to name a few and there are others.

Here I hope each representative doctor poster will ask or give input. This is one of my favorite topics because of the physiology aspect. Grafts have a shelf life of 12-24hrs depending on conditions. Here are other interestin facts of other transplantable tissue:

Heart: Has to be beating in another chest within a strict 4 hrs after being cut out of the donor’s chest. Typically stored in UW cold solution. (UW is a solution made by the university of Wisconsin)

Liver: Has to be in recipients chest within 12hrs. Stored in UW.

Lungs: I forgot this one but I suspect similar to heart.

Kidneys: Has 48hrs to be back to making urine. Is either cold storaged or placed on a pump that pumps fluid through it continuously until recipient found. UW is used

Corneas: Can be held for two weeks in it’s holding solution called Optisol GS. The GS is gentamycin sulfate. Optisol GS is unique. Also what is used in eyebanking is BSS or balancing salt solution.

Bones: Are stored in saline and then freezed at -72Celsius

Saphenous veins: Are first injected with papavrin then stored in UW and are processed to be able to use almost indefinitely.

Cooley has much research in this area too. Dr. Cooley’s words below:
Dr. Cooley asked me to post this as it is his quote:

"Hi Thomas

Thanks for the email. I’m on vacation in Italy but maybe you could post this for me. By the way, I’m glad to hear you’re with Harris. He’s a great guy and there you can use all your skills.

best,

Jerry

Holding solutions…Are they important?

I have used alternative holding solutions for over ten years and have been very interested in this topic. The ‘standard’ holding solutions are normal saline and lactated ringers solution. Careful follicular unit surgery techniques and use of these standard solutions generally results in very good results. The bottom line is that for smaller cases and those lasting less than four to five hours, it may not matter.

In my opinion, using alternative holding solutions could give small but significant improvement in graft survival for cases lasting longer than five hours or greater than 2000 grafts. In our clinic, we place the strip and ‘slivers’ in HypoThermosol at 4-10 degrees celsius. IMO, this provides the greatest protection for grafts outside the body. For dissected grafts waiting to be placed, we put the grafts in cell culture solution (DMEM with HEPES buffer) for protection at room temperature. This solution has glucose, amino acids, buffers to protect the tissue.

Dr Carlos Uebel in Brazil has used a technique with patient derived plasma to create a gel, which is used to coat the grafts before placement. This has growth factors which supposedly speeds up the healing process and revascularization. This is not a ‘holding solution’. It is very interesting but should be considered experimental until more data is available.

Jerry Cooley MD
Charlotte North Carolina"

Thomas Ortiz, BS
Hair Technologist
James Harris, MD

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Hairtec,

I think this is a great discussion and possibly very important. Thank you for opening this up. I would like to give my very biased opinion that HT surgeon know little about these areas and we should not take them as experts. The likes of “hair cycle” advertised by coles clinic or other issues such as this are best addressed by biochemists and physiologists rather than surgeons.

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I have read the study before. What about Choi or DHI’s no touch technique? Do you know how that works? They claim each graft is placed immediately. How is that possible?

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» Hairtec,
»
» I think this is a great discussion and possibly very important. Thank you
» for opening this up. I would like to give my very biased opinion that HT
» surgeon know little about these areas and we should not take them as
» experts. The likes of “hair cycle” advertised by coles clinic or other
» issues such as this are best addressed by biochemists and physiologists
» rather than surgeons.

We have a chemist and an expert on natural/holistic medicine on staff. What would you like to know? I can ask them.

5

» I have read the study before. What about Choi or DHI’s no touch technique?
» Do you know how that works? They claim each graft is placed immediately.
» How is that possible?

The Choi implanter is not as popular in the US as it is in other places, especially in Asia. I think the main reason for this might be because it was designed with Asian hair in mind, which is very straight and the follicles have little splay. The implanter doesn’t work well for grafts that have curl to them or follicular units that take up more epidermal surface area. I have heard people say that the implanter can cause more trauma to the grafts, but I haven’t seen any evidence of this. When used on the right patient and by a person specifically trained with the implanter, it probably turns out just fine. Personally, I like to place the grafts myself rather than with an implanter.

Here’s a link with pictures and a diagram of the implanter:

“Looking a little like a syringe, the Choi has a hollow needle which holds the graft and once in the head, the hair is literally injected into a pre-made pinprick.”

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Does anyone want to know what clinics use what(holding solutions)? I can post what I know later… I’m having father’s day diner at the moment.

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» » surgeon know little about these areas and we should not take them as
» » experts. The likes of “hair cycle” advertised by coles clinic or other
» » issues such as this are best addressed by biochemists and physiologists
» » rather than surgeons.
»
» We have a chemist and an expert on natural/holistic medicine on staff.
» What would you like to know? I can ask them.

Sorry Jessica, I should possibly not have singled out a particular clinic in that comment. The point is that pretty much most, if not all, natural treatments such as hair cycle have no acceptable supporting evidence to back them up at all. Biotin and Saw palmetto do not have any good evidence to support their use for hairloss. Saw palmetto has no impact on serum DHT whatsoever for instance. If a clinic supports them with any certainty then it raises questions regarding the certainties placed on other areas of the practice in my view. If you can offer a rationale for the use of hair cycle to any theoretical or evidential extent equalled to fin or minox then I would be very interested.

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» Does anyone want to know what clinics use what(holding solutions)? I can
» post what I know later… I’m having father’s day diner at the moment.

Why do you post…hairtech …at the end of your subject
its already posting hairtech for you

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,

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Hanging in there…
I just have always done that… hairtech at the end, not really thought about it since 2003.

Anyway, some info on who does what in holding solutions. These are the clinics I know first hand:

Dr. Harris uses Plasmalyte A.
Dr. Jerry Cooley uses a combination of DMEM and Hyperthermasol.
Dr. Rose uses 0.9%Saline.
Dr. Mwamba uses BSS and some experimentation of hyperthermasol as of January 2007.
Bosley uses saline.
MHR uses 0.9% saline.
PAI uses 0.9% saline.
NUHART uses 0.9% saline.

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I am bringing this thread up again to compare different holding solutions. I will collect data and post it when I get it. Below is a holding solution that one clinic uses.

One liter of Lactated Ringer’s Solution contains:

  • 130 mEq of sodium ion = 130 mmol/L.
  • 109 mEq of chloride ion = 109 mmol/L.
  • 28 mEq of lactate = 28 mmol/L.
  • 4 mEq of potassium ion = 4 mmol/L.
  • 3 mEq of calcium ion = 1.5 mmol/L .
    Ph is 6.0 7.5
    Generally, the sodium, chloride, potassium and lactate come from NaCl (sodium chloride), NaC3H5O3 (sodium lactate), CaCl2 (calcium chloride), and KCl (potassium chloride).
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Another clinic uses:

PLASMA-LYTE A Injection pH 7.4 (Multiple Electrolytes Injection, Type 1, USP) is a sterile, nonpyrogenic isotonic solution in a single dose container for intravenous administration.
Each 100 mL contains:

526 mg of Sodium Chloride, USP (NaCl)
502 mg of Sodium Gluconate (C6H11NaO7)
368 mg of Sodium Acetate Trihydrate, USP (C2H3NaO2·3H2O)
37 mg of Potassium Chloride, USP (KCl)
30 mg of Magnesium Chloride, USP (MgCl2·6H2O).

It contains no antimicrobial agents. The pH is adjusted with sodium hydroxide. The pH is 7.4 (6.5 to 8.0).

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» Another clinic uses:
»
» PLASMA-LYTE A Injection pH 7.4 (Multiple Electrolytes Injection, Type 1,
» USP) is a sterile, nonpyrogenic isotonic solution in a single dose
» container for intravenous administration.
» Each 100 mL contains:
»
» 526 mg of Sodium Chloride, USP (NaCl)
» 502 mg of Sodium Gluconate (C6H11NaO7)
» 368 mg of Sodium Acetate Trihydrate, USP (C2H3NaO2·3H2O)
» 37 mg of Potassium Chloride, USP (KCl)
» 30 mg of Magnesium Chloride, USP (MgCl2·6H2O).
»
» It contains no antimicrobial agents. The pH is adjusted with sodium
» hydroxide. The pH is 7.4 (6.5 to 8.0).

Hairtech,

Will you please address this in layman’s terms for the benefit of the average patient? Those of us within the industry know these solutions help to retard the magnetizing effect of free radicals to tissue taken outside of the body, its natural environment. Obviously employing these solutions can help with graft survival. Can you explain the ramnifications to the patient?

I thought you might want to address this issue for patients since you started this thread. Good thread.

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Good point Gill… I’m working at the moment but i’ll get on it ASAP.

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At the moment I am still collecting data concerning the properties of every holding solution used out there. It is a spread sheet that I should have soon.

In the mean time… What the heck are you talking about? What are holding solutions? Why have them? Well, holding solutions have become increasingly popular in hair transplantation in the last few years. To make a complicated story short, read the following:

When follicles are out of its natural environment, i.e. the the scalp or the body… they are immediately undergoing a great amount of stress. The hairs/follicles are still living tissue. They are still metabolizing nutrients, electrolytes, and oxygen. The hairs are undergoing oxidative stress from free radicals as Gill has pointed out. Ph change is also occurring. Let’s first discuss Ph.

What is Ph? Ph is a way to give a number to something to relate how acidic neutral or basic a solution is. Ph is important because solutions that are too acidic or too basic can cause tissue harm. Solutions that cannot keep a Ph steady can also be potentially harmful to tisshue and especially hair follicles as this is our main concern here.

Ph is defined as 0.0-6.9 is acidic, 7.1-14.0 is alkaline.

An example of the Ph of orange juice is around 3. Very acidic. Even more acidic than that would be stomach acid, which is around Ph 1.5 to Ph 2.

Milk is somewhere around Ph 9 which is alkaline or basic

Ph of 7 is water or neutral.

The Ph of human blood is around 7.2-7.3.

Now having said this, all solutions that are holding solutions start out with a Ph number or a Ph range. A holding solution, should keep a Ph steady around a narrow range. WHEN HAIR FOLLICLES SIT IN THE HOLDING SOLUTION, THEY ARE GIVING OUT WASTE PRODUCTS AS THE CELLS CONTINUE TO METABOLIZE NUTIENTS, ETC. These waste products have the potential of dropping a Ph low in general. Heck one study I was involved in at this other clinic, proved that just letting air touch holding solutions, shifted a Ph dramatically. So this is important.

Saline is used as the holding solution in most clinics still today. Saline at 0.9% in open air will drop in Ph without any follicles sitting in it. Kind of scary when you think about it and especially during FUT. I have to go to work but will discuss electrolyte relevance next.

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Everyone has heard of electrolytes right? They are extremely vital fo ALL cellular functions. When this is disrupted, many things can go wrong. Cells, including hair follicle cells can begin to gain water or even dehydrate and “shrink” when electrolytes begin to become unbalanced. Below that is a description of 4 different very important electrolytes.

What are electrolytes?

Electrolytes are substances that become ions in solution and acquire the capacity to conduct electricity. The balance of the electrolytes in our bodies is essential for normal function of our cells and our organs.

Common electrolytes that are measured by doctors with blood testing include sodium, potassium, chloride, and bicarbonate. The functions and normal range values for these electrolytes are described below.

Sodium: Sodium is the major positive ion (cation) in fluid outside of cells. The chemical notation for sodium is Na+. When combined with chloride, the resulting substance is table salt. Excess sodium (such as from fast food hamburger and fries) is excreted in the urine. Sodium regulates the total amount of water in the body and the transmission of sodium into and out of individual cells also plays a role in critical body functions. Many processes in the body, especially in the brain, nervous system, and muscles, require electrical signals for communication. The movement of sodium is critical in generation of these electrical signals. Too much or too little sodium therefore can cause cells to malfunction, and extremes (too much or too little) can be fatal. A Normal blood sodium level is 135 - 145 milliEquivalents/liter (mEq/L), or in international units, 135 - 145 millimoles/liter (mmol/L).

Potassium: Potassium is the major positive ion (cation) found inside of cells. The chemical notation for potassium is K+. The proper level of potassium is essential for normal cell function. Among the many functions of potassium in the body are regulation of the heartbeat and function of the muscles. A seriously abnormal increase of potassium (hyperkalemia) or decrease of potassium (hypokalemia) can profoundly affect the nervous system and increases the chance of irregular heartbeats (arrhythmias), which, when extreme, can be fatal.

The normal blood potassium level is 3.5 - 5.0 milliEquivalents/liter (mEq/L), or in international units, 3.5 - 5.0 millimoles/liter (mmol/L).

Chloride: Chloride is the major anion (negatively charged ion) found in the fluid outside of cells and in blood. An anion is the negatively charged part of certain substances such as table salt (sodium chloride or NaCl) when dissolved in liquid. Sea water has almost the same concentration of chloride ion as human fluids. Chloride also plays a role in helping the body maintain a normal balance of fluids.

The balance of chloride ion (Cl-) is closely regulated by the body. Significant increases or decreases in chloride can have deleterious or even fatal consequences:

* Increased chloride (hyperchloremia): Elevations in chloride may be seen in diarrhea, certain kidney diseases, and sometimes in overactivity of the parathyroid glands.
* Decreased chloride (hypochloremia): Chloride is normally lost in the urine, sweat, and stomach secretions. Excessive loss can occur from heavy sweating,  vomiting, and adrenal gland and kidney disease.

The normal serum range for chloride is 98 - 108 mmol/L.

Bicarbonate: The bicarbonate ion acts as a buffer to maintain the normal levels of acidity (pH) in blood and other fluids in the body. Bicarbonate levels are measured to monitor the acidity of the blood and body fluids. The acidity is affected by foods or medications that we ingest and the function of the kidneys and lungs. The chemical notation for bicarbonate on most lab reports is HCO3- or represented as the concentration of carbon dioxide (CO2). The normal serum range for bicarbonate is 22-30 mmol/L.

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So far we have covered two aspects of the importance of holding solutions, Ph and electrolytes. I have two more to cover possibly three.

Next in line… “buffers”. Buffers relate to Ph. Buffers in solutions can sort of be related to buffers like when using the term in computers. A computer buffer is a small storage or holding area. A buffer in a solution is sort of the same thing… it holds the Ph between a range. WHAT?? :roll:

Let me give an example. Lets say you have a gallon of water (Ph 7). Lets add an acid to it. Now the Ph has dropped to Ph 4. Now for what ever reason, you need that Ph to remain at Ph 4 and not shift to Ph 2 or Ph 3. Well in order to do that you have to add a “buffer”. A chemical that when mixed with your gallon of water/acid at Ph 4… will be able to keep that solution at Ph 4 no matter what you add to it. Acetate and HEPES are common names for buffers.

Now let’s relate this back to our holding solution. A good holding solution will hold the Ph at physiological Ph or there abouts. So far as I have been compiling the data of different holding solutions, I am noticing that some do not have this component.

(0.9%) Saline alone contains NO BUFFER whatsoever. So when grafts sit in saline for extended periods of time, one can with confidence assume the Ph will shift as time goes on.

So this is another reason alternative holding solutions were looked at.

Next we will look at glucose/calories/ “GRAFT FOOD” if you will. Calories are needed for all cells to continue to live.

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Now let’s talk about how grafts sort of eat and how it relates to holding solutions. Below is a basic breakdown of “glucose” and its structure. Glucose comes in a few different ways within holding solutions. So what is glucose?

Glucose (Glc), a monosaccharide (or simple sugar), is an important carbohydrate in biology. The cell uses it as a source of energy and metabolic intermediate. Glucose is one of the main products of photosynthesis and starts cellular respiration.

Glucose is a ubiquitous fuel in biology. It is used as an energy source in most organisms, from bacteria to humans. Carbohydrates are the human body’s key source of energy, through aerobic respiration, providing approximately 4 kilocalories (17 kilojoules) of food energy per gram. Breakdown of carbohydrates (e.g. starch) yields mono- and disaccharides, most of which is glucose .

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OOOOOOOOOk… We have discussed Ph, electrolytes, buffers, and glucose. All important ingredients that go into “holding solutions”. And especially in FUT. And for that matter, in my opinion ALL procedures.

There is one more discussion that is widely overlooked and is somewhat debatable in terms of its relevance… Free radical damage that can potentially harm grafts when exposed to air.

Let’s discuss what free radicals are:

I have used the term oxidative stress. This term can be defined by its words. Oxidative means oxygen… which for our purposes here means exposure to air. Simply put when something rusts… that means it has undergone oxidative stress or oxidation. Exposing iron to air produces rust by way of a type of free radical damage called oxidation.

For our purposes here follicles exposed to “air” can not only be succeptable to dehydration but also “free radical” damage by oxidation. More specifically, AND IN THEORY ONLY… Free radical damage may cause hair follicles cells to be signaled to begin “apoptosis”.

In other words, and in theory only. Air exposure may/may not turn the switch on in a hair follicle to begin to die faster.

Holy mackeral. What do we do now? Well there are protectors of free radicals, oxidation, oxidative stress, etc. These are mostly anti-oxidants. And various synthetic chemicals, ie glutathione and Hypo-thermosol are seen to be great protectors and are seen in some holding solutions.

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Now I will provide a side by side comparison of typical holding solutions used in HT today. I am still collecting the product inserts at this time.